Behavioral Interventions for Prevention and Control of Sexually Transmitted Diseases

Behavioral Interventions for Prevention and Control of Sexually Transmitted Diseases

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Behavioral Interventions for Prevention and Control of

Sexually Transmitted Diseases

Sevgi O. Aral, Ph.D.

John M. Douglas, Jr., M.D.

Editors

Judith A. Lipshutz, M.P.H.

Associate Editor

Division of STD Prevention

National Centers for HIV, STD, and TB Prevention Centers for Disease Control and Prevention

Atlanta, Georgia, USA

Foreword by H. Hunter Handsfield and Edward W. Hook III

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ISBN-13: 978-0-387-47863-0 e-ISBN-13: 978-0-387-48740-3

Library of Congress Control Number: 2006937338 Printed on acid-free paper.

© 2007 Springer Science+Business Media, LLC

The findings and conclusions in this book are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden.

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Foreword

1

Parran T. Shadow on the Land: Syphilis. New York: Reynal and Hitchcock; 1937.

It goes without saying that sexually transmitted diseases (STDs) are conse- quences of human behavior at the individual and community levels, and it stands to reason that behavioral interventions can and should contribute to STD control efforts. This is not a new idea. Throughout most of human his- tory, the lack of effective therapy or other biomedical means of control required reliance on rudimentary behavioral strategies in attempts at preven- tion. Approaching the modern era, the import of behavioral assessment and intervention was emphasized by Thomas Parran, the surgeon general of the United States, in his groundbreaking road map for syphilis control, Shadow on the Land.

However, notwithstanding Dr. Parran’s insight, the dawning of the antibi- otic era, soon followed by the burgeoning of microbiology, immunology, and epidemiology, ushered in an era in which markedly improved diagnosis, treat- ment, and understanding of the at-risk populations pushed behavior into the background. By the 1970s and early 1980s, seemingly the main solutions to control syphilis, gonorrhea, and emergent chlamydial infections were the resources and political will to apply the rapidly evolving biomedical knowl- edge. There was continued acknowledgment that sexual behavior, at both individual and societal levels, was fueling the rapidly rising tide of bacterial STDs, and that behavioral intervention had a potential role in prevention.

However, for many generations, the public health establishment had been advising sexually active people to avoid commercial sex, to use condoms out- side committed partnerships, and to seek care promptly when they developed symptoms. It was understood that many persons at risk did not follow that sage counsel, but what more could be done except to say it again? If we could not prevent people from becoming infected, at least screening, early diagno- sis, and prompt treatment would make serious morbidity a thing of the past.

Then along came AIDS, growing awareness of the importance of genital herpes and sexually transmitted hepatitis, and understanding that many human papillomavirus infections are more than benign inconveniences. All of a sudden,

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our biomedical prevention emperor appeared thinly clothed indeed. Without curative treatment, early diagnosis of human immunodeficiency virus infec- tion offered little obvious benefit to infected individuals. Diagnosing incurable HIV infections seemed a hollow victory, and gradually, it became apparent that screening and counseling uninfected people had little of the expected ben- efit in preventing transmission. Absent protective immunization, the only strat- egy even theoretically available to prevent accelerating transmission of the viral STDs was to understand and ultimately to influence partner selection, sex partner numbers, sexual practices, use of condoms, and the use of mind- altering substances, both at the individual level and in populations.

Thus, the emergence of AIDS and heightened appreciation of the impact of other viral STDs raised awareness that behavior matters more than theoreti- cally. Furthermore, the forced attention on behavioral interventions prompted understanding that biomedical strategies are inherently insufficient to control any STD. Over the last twenty-five years, we have come to understand that behavior—of infected persons, of their sex partners and other persons at risk, of health care providers, of partner networks, and of entire populations—is central to success of the biomedical interventions themselves. Who visits settings where screening, diagnosis, and treatment can be implemented, and why?

What factors influence persons’ decisions to continue, cease, or modify their sexual behaviors in response to symptoms consistent with STD and to seek medical attention? What about compliance with therapy and follow-up? What do people do and not do to ensure that their partners are evaluated and treated, and what determines the partners’ responses? What do health care providers ask or counsel their patients about risky behaviors, who do they screen, what do they understand about recommended screening criteria and treatment, and why do they use the tests and drugs they use? And, ultimately, how can we get persons at risk, those infected with STDs, their partners, and their providers to modify all these and many other behaviors to help curtail STD transmission?

Even during the heyday of biomedical prevention, a few colleagues under- stood what effective prevention would require, citing new models that integrated infected persons and those at risk, health care providers, social exchange, and the cultural environment. And experts historically linked to biomedical strate- gies began to see the light. For example, King Holmes brought a polymath’s understanding to the biomedical paradigm and tirelessly promoted the impor- tance of the behavioral sciences in STD prevention, with emphasis on the career development of social and behavioral scientists. We turned to these and other colleagues, and they opened our eyes and continue to do so.

For clinicians and public health experts, these early contributors, their peers, and their intellectual successors have provided heightened appreciation not only of the import, but also of the complexity of modifying behaviors that contribute to STD prevention and management. No longer do prevention experts consider simplistic exhortations to “just say no” or “use condoms” to be appropriate or meaningful interventions. Increasing appreciation and use of theories of behavior change, carefully crafted approaches to counseling, vali- dated measures for evaluating behaviors, and critical assessment of interven- tion strategies are now increasingly embedded as crucial elements of successful STD control.

Thus, from humble beginnings dating to Dr. Parran comes this book, the first text to systematically summarize the science of behavioral interventions vi Foreword

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to prevent STDs. From theoretical underpinnings to pragmatic application, this work addresses behavioral approaches to prevention at the individual and pop- ulation levels, methodologies to measure their effectiveness, and the profound policy and ethical implications. It is expected that this work not only will con- tribute directly to improved STD prevention, but also will stimulate further creative development of this enormously important and significant field.

H. Hunter Handsfield, M.D.

Battelle Research and University of Washington Seattle, Washington

Edward W. Hook III, M.D.

University of Alabama at Birmingham Birmingham, Alabama

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ix

Introduction

Sevgi O. Aral, Ph.D., Judith A. Lipshutz, M.P.H., and John M. Douglas, Jr., M.D.

The landscape for the prevention of sexually transmitted diseases (STDs) has shifted ground over the last twenty years. A multitude of prevention trials con- ducted during this time along with developments in the closely related field of HIV prevention provide STD program managers and public health workers with many choices. Yet, at the same time, declining resources for STD pre- vention render decision making exponentially more difficult. A recent review of research on interventions for prevention of sexually transmitted infections (STIs) concluded that although many interventions were found to be effective few have been replicated, widely implemented, or carefully evaluated for effectiveness in other settings (1).

This compendium of the major behavioral interventions for prevention and control of STDs aims to provide easily accessible information on the social and behavioral parameters of STD prevention so that public health students and public health practitioners can more easily make choices in a field that has his- torically been and continues to be based primarily on biomedical interventions.

Choices

The decisions to be made by public health workers extend beyond the choice of interventions. Each specific intervention needs to be considered within the framework of a holistic plan that takes into account a number of factors:

– the prevalence, incidence, and distribution of infection(s);

– the epidemic potential for each infection;

– the prevalence, incidence, and distribution of risk and preventive behaviors;

– the incipient decline or increase in risk and preventive behaviors;

– the mix and coverage of interventions currently being implemented;

– costs and cost-effectiveness of available efficacious interventions;

– available resources and incipient decline or increase in such resources;

– health system parameters such as feasibility of implementation of interven- tions, sustainability of interventions, and feasibility of scale-up;

– estimates of achievable coverage as compared to estimates of coverage required for desirable impact;

– structures and processes that need to be put in place for quality assurance and continuous quality improvement after the implementation of the intervention.

Moreover, in light of scarce and declining resources, all choices involve difficult trade-offs.

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Efficacy and Effectiveness

While at this time a considerable number of biomedical and behavioral inter- ventions have been shown to be efficacious in randomized trials for the preven- tion of STDs, the effectiveness of these interventions outside the randomized trial context is often not well understood. Often, we know an intervention works if and when it is implemented correctly and consistently in a population similar to that in which it was tested, but we have limited knowledge regarding the extent to which correct and consistent implementation will occur and generalizability of the results of the intervention to other populations and other contextual situa- tions (2). Two, by now classical, examples of efficacious practices of unknown effectiveness are abstinence and condom use. The former works in preventing the acquisition of all STIs and the latter works in decreasing the risk of acquisition for most STIs (3). However, individual people do not necessarily implement these practices correctly and consistently. Clearly, for STD prevention programs, the important factor is intervention effectiveness in the everyday context and not intervention efficacy as defined in the context of randomized controlled trials.

Moreover, public health professionals lack information that would help predict the conditions under which these interventions may be effectively implemented by different subpopulations in different situations. The extent to which specific subpopulations deviate from consistent and correct implementation of an inter- vention and the impact of various contexts on such deviations have important implications. Such deviation on the part of subpopulations marked by low-risk behaviors and low prevalence of STIs may not carry much significance; how- ever, even small deviation from correct and consistent implementation on the part of subpopulations marked by high-risk behaviors and/or high prevalence of STIs may contribute prominently to STI transmission. Conversely, correct and consistent implementation of an intervention for subpopulations marked by low-risk behaviors and low STI prevalence may not have much impact on population-level prevalence and incidence of STIs. Yet, correct and consistent implementation of the same intervention for subpopulations marked by high-risk behaviors and/or high prevalence and incidence of STIs may have great impact on health outcomes at the population level.

Effectiveness and Impact

The goal of STD public health interventions is to decrease the incidence and prevalence of specific STDs at the population level. In contrast to chronic dis- ease prevention, which provides prevention benefit for the individual, infectious disease prevention interventions can be beneficial at both the individual and the population levels by preventing ongoing transmission. Yet, efficacious and even effective interventions may or may not have population-level impact depending on critical parameters that include prevalence, incidence, distribution, and epi- demic potential of infection; prevalence, incidence, distribution, and incipient decline (or increase) of risk and preventive behaviors; and required and achieved levels of coverage of the intervention. The required level of coverage depends on the efficacy and effectiveness of the intervention under consideration as well as the networks in which the populations live. Highly efficacious/effective inter- ventions may have population-level impact even at relatively low levels of cov- erage. On the other hand, interventions of relatively low efficacy may result in x Introduction

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significant population-level impact when combined with high levels of coverage.

For example, relatively low-efficacy vaccines can reduce the prevalence of infec- tion in whole populations when full coverage is achieved (4).

Neither STIs nor risky or preventive behaviors are distributed evenly through populations. Consequently, coverage in some subpopulations is more critical to the achievement of population-level impact compared with coverage in other subpopulations. As a rule, for STD prevention and control, coverage in subpopulations marked by high-risk behaviors and high prevalence or inci- dence of STIs is more crucial than coverage in subpopulations marked by low- risk behaviors and low prevalence/incidence of STIs. The former have greater potential to contribute to STI spread. Often, subpopulations marked by lower behavioral and infection risk are faster in intervention uptake than those with greater behavioral and infection risks. Unfortunately, coverage in these lower risk populations generally contributes to population-level impact only in limited ways.

The concept of population-level impact associated with a specific interven- tion, implemented in a specific subpopulation, has been described earlier for non-infectious diseases (5). More recently, this “impact fraction” model developed for chronic conditions was adapted for STD and HIV (6). The

“prevention impact model,” adapted from St. Louis and Holmes (6), defines population-level impact of an intervention as

Introduction xi

Incremental Impact and Saturation

As interventions are considered for implementation, it is important to focus on their potential “incremental” (as opposed to “absolute”) impact on the health outcome of interest as well as on their potential saturation point. Interventions introduced relatively early in an epidemic in appropriately targeted popula- tions tend to have greater impact on the prevalence and incidence of STIs than do interventions implemented later (7). Furthermore, as interventions are introduced, the incremental impact of each additional intervention can be smaller than expected due to the “saturation” effect. This pattern may be par- ticularly relevant for behavioral interventions, since the elasticity (potential for change) of behaviors and/or the ability of the individuals to control their situation—and consequently their behaviors—may be limited. For example, most people find it difficult to abstain from sex for long periods of time.

Similarly, many married women in developing countries find it difficult to use a condom against their husbands’ wishes. Though public health workers encourage reduction in the number of sex partners, it is likely that most targeted persons will not find it feasible to give up a last, remaining sex partner.

Similarly, once the early adopters and the easy-to-influence subpopulations have changed their behaviors, it may be particularly difficult to effect change in the behaviors of the remaining, relatively small proportion of the population (8).

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This is one of the reasons why it is difficult to eliminate or eradicate adverse health outcomes after their prevalence and incidence are reduced to low levels.

Issues of saturation and diminishing, incremental impact may also be relevant for biomedical interventions. For example, the addition of an HPV 16/18 vaccine campaign may not make as large an impact on reduction of cervical cancer in a population already well covered by Pap testing as in an area with no cervical cancer prevention programs. As both biomedical and behavioral interventions are introduced and continually implemented, their incremental impact on the prevalence and incidence of STIs and their sequelae may start declining.

The Intervention Mix: Duplication, Saturation, and Synergy

At any point in time, public health programs are likely to implement a multiplicity of interventions to prevent the spread of STIs in general and of specific infections in particular. Some of these interventions target the same subpopulations, while others cover different subpopulations. When the same subpopulation is targeted by several interventions concurrently, prevention efforts may be duplicative.

Similarly, when the same subpopulation is targeted by a number of interventions, concurrently or sequentially, the incremental impact of each intervention may be limited because of the saturation effect. In this context, it is important both to anticipate that diminishing marginal (or incremental) returns will occur at some point and to monitor the results of investments in interventions.

The goal of public health is to identify a package or mix of interventions with synergistic, as opposed to duplicative or opposing, effects. For example, the combination of enhanced clinical services with health promotion was key to the successful reduction of syphilis in the United States in the late 1990s (9).

Another example of a multilevel intervention mix aimed at synergistic effects on increased primary prevention of STDs in adolescents is Project Connect (10). In this project, parents, health care providers, and schools are targeted simultane- ously with the ultimate goal of delaying sexual debut and increasing safer sex following initiation of intercourse in middle school and high school students.

Packages of biomedical interventions coupled with behavioral interventions to magnify their effects may be particularly synergistic and effective. For example, increased screening and treatment efforts for bacterial STIs may be combined with behavioral interventions to enhance health care seeking by at-risk populations and expanded partner referral among providers.

Preventing Acquisition and Transmission of Infection

Prevention of STDs involves ensuring that uninfected persons avoid acquiring infection and that infected persons avoid transmitting their infection to suscep- tible sex partners. While prevention of acquisition requires that public health interventions target the very large numbers of uninfected persons, prevention of transmission allows interventions to target the smaller numbers of those who are infected. In light of limited resources, choices often need to be made about which subpopulations to target. Possible alternatives include

– infected persons with high-risk behaviors (high-frequency transmitters);

– infected persons with low-risk behaviors;

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– high-risk but uninfected persons;

– low-risk, uninfected persons.

Especially for bacterial STIs, which are relatively uncommon in most popula- tions, a focus on prevention of transmission from infected populations rather than prevention of acquisition by uninfected populations may be a more efficient and cost-effective approach to decreasing prevalence and incidence of STIs in the population. However, such an approach may run contrary to the desire of public health practitioners and public health agencies to inform and educate the general population about how to protect themselves from infections, including STIs.

Historically, STD programs have prioritized the so-called “core groups” in prevention and control efforts (11). While core groups have been defined in many different ways in the literature, all definitions include the elements of high prevalence and incidence of infection and risky behaviors. Core groups have been conceptualized as subpopulations that contribute particularly to the spread of infection in the population. Perhaps a revised approach might adopt a hierarchical ranking of subpopulations. Infected persons with high-risk behav- iors that transmit infection (e.g., core groups) may be the top-priority subpopu- lation, followed by infected persons with low-risk transmission behaviors.

Next on the hierarchy would be uninfected persons with high-risk behaviors that result in acquisition of infection followed finally by uninfected persons with low-risk acquisition behaviors. To the extent allowed by resource availability, prevention programs could attempt to cover all of the above-named subpopula- tions. Where resource limitations restrict coverage, the hierarchical ranking mentioned above may provide guidance for resource allocation (see Figure 1).

Introduction xiii

Figure 1

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Intended and Unintended Consequences of Interventions

All public health interventions intend to decrease negative health outcomes in populations; however, interventions may have unintended consequences. For example, it is often suggested that the campaign to decrease the fat intake of Americans resulted in significant increases in carbohydrate intake and associated weight gain. Some argue that America’s recent obesity epidemic is a direct result of the earlier low-fat prevention campaign (12,13). Similar unintended consequences can occur in STD prevention. Recent increases in bacterial STI incidence in men who have sex with men (MSM) have, in many parts of the world, been attributed not only to “prevention fatigue”

associated with HIV prevention efforts but also to “disinhibition” resulting from the availability of antiretroviral therapy (14,15).

As discussed earlier, in making decisions about interventions, it is important to focus on the expected incremental, as opposed to the absolute, impact of the intervention. Similarly, in considering the potential impact of possible disin- hibition associated with a specific intervention, it is important to look at the incremental (and not absolute) disinhibition. In the presence of a multiplicity of interventions for the prevention of STDs including HIV, the incremental disin- hibition associated with any specific intervention is likely to be limited (15).

Cost, Cost-Efficacy, and Cost-Effectiveness

Every decision in a prevention program is associated with costs, and choosing interventions based on cost-effectiveness considerations has become an increasingly common approach to prevention. Yet, some raise serious objec- tions to this approach. First, most cost-effectiveness analyses are based on data collected during efficacy trials, and they provide information on cost-efficacy rather than cost-effectiveness (16). Costs incurred in the context of a random- ized trial may be higher (or lower) than costs incurred in the implementation of an intervention outside of the trial context (16). Second, cost-effectiveness may be given more consideration than prevention effectiveness, thereby prior- itizing economic outcomes over and above health outcomes (17). Perhaps a sequential approach to decision making should prioritize interventions based first on the importance of the health outcome, second on the effectiveness of the interventions, and finally on the cost-effectiveness analysis (CEA) (not cost-efficacy) of equally effective interventions.

Multiple Epidemics; Multiple Populations

More often than not, an STI epidemic in a local area is composed of multiple epidemics in multiple subpopulations, each of which is in a different point in the epidemic trajectory (18,19). Thus, it is important for program managers to know which subpopulations are involved and whether the specific epidemic in a specific subpopulation has peaked or is just starting. Understanding the social determinants of STI epidemics, knowledge of the current social and economic context of subpopulations, and recent behavioral trends in subpop- ulations can help program managers analyze their current situation and predict where the next epidemic may take place. In this context, information regard- ing the social, cultural, economic, and behavioral factors that characterize xiv Introduction

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subpopulations is important. It is such understanding that enables STD program managers to choose the most effective intervention packages and to target strategies of greatest impact. Interventions that may be most appropriate for one subpopulation may not be optimal for another.

Characteristics of STD Pathogens and Implications for Interventions

Characteristics of STDs often influence the choice of biomedical and behavioral interventions. Such characteristics include transmissibility; duration of infec- tion; frequency and type of symptomatology; epidemiologic characteristics such as prevalence and incidence in the population as well as the partner pool; char- acteristics of available (and implemented) interventions; availability of a pre- ventive vaccine and curative or suppressive antimicrobial therapy; and whether or not condoms or microbicides can reduce transmission of the particular pathogen. Recent work (20,21) suggests that some behavioral interventions may be more effective in preventing bacterial STIs, whereas others are more effective in preventing viral STIs. For example, a reduction in numbers of sex partners is more effective in reducing the incidence of gonorrhea and chlamydia (highly transmissible, curable infections), whereas a reduction in numbers of episodes of sexual intercourse with one partner is more effective in reducing the incidence of HIV (low transmissibility, incurable infection) (22). Screening—a widely used prevention intervention—is often used for relatively widespread and often asymptomatic infections such as those caused by Chlamydia trachomatis. In contrast, for relatively uncommon infections like syphilis, interventions such as partner management may play a relatively more important role.

Social Determinants, Future STI Trends, and Multiple Levels of Social–Behavioral Interventions

Many societal factors play a role in the determination of STI epidemiology. Such societal determinants include the demographic and socioeconomic structure of the population; the political environment and its effects on the composition of the unemployed and incarcerated populations; distribution of access to accept- able and quality health care and prevention services; social and sexual network characteristics; gender power dynamics; and sexual behaviors of different sub- populations (23). A look at these and other similar factors suggests that trends in STI incidence in the near future may create even greater challenges for STD pre- vention programs faced with limited and declining resources. The relatively larger size of “generation Y” portends increases in the size of sexually active age groups, and the recent increases in poverty and inequality levels suggest increased vulnerability of the population to STIs, all predictors of increased STI incidence. In this alarming context, multilevel social and behavioral interven- tions, ranging from the structural and policy level to couples and individual per- sons, constitute an important element of the STI prevention toolbox.

Volume Contents

This book is divided into five parts. The overview chapters set the stage for the intervention approaches discussed in subsequent parts. McGough and Handsfield provide a rich historical summary of STD prevention and control

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up to the modern AIDS era, when behavioral interventions started becoming more mainstream. St. Lawrence and Fortenberry give a comprehensive review of theories in behavioral science and intervention methods, providing the reader with a thumbnail sketch of the most important underpinnings of behavioral interventions. Given that behavioral interventions occur within what has traditionally been a biomedical field, Berman and Kamb offer a look at transmission dynamics through the lens of the Anderson–May equa- tion, R = bcd (24). They focus on two parameters that have critical interface with behavioral interventions—duration of infectivity (d) and transmissibil- ity (b).

Following this overview, Part 2 addresses different STD intervention approaches, some related to population levels and some related to specific interventions. McCree et al. discuss behavioral interventions that specifically target couples, small groups, and communities. Moving to a larger population level and one of the newest areas of behavioral intervention research, Bloom and Cohen focus on structural-level interventions that attempt to change the context in which behaviors take place. Structures can include public and private institutions, service and educational systems, and laws and regulations.

Similarly, Vega and Ghanem write about the importance of social marketing in behavior change. Social marketing campaigns for STD prevention, they contend, require not only mass communication to inform the public, but also techniques that persuade people to actually practice prevention.

The next group of chapters in Part 2 reviews more familiar STD prevention interventions. Hogben et al. focus on the classic topic of partner notification, reflecting both historical approaches and more recent innovations such as part- ner-delivered therapy. In the following chapter, Hogben and Schrier write about the health care system from the perspective of those who provide the care as well as those who seek it. Discussion in that chapter reflects assumed goals of public health: to increase routine prevention (e.g., yearly doctor vis- its) and to optimize reaction to a suspected infection. The Internet, discussed in the chapter by McFarlane and Bull, is perhaps one of the most widely dis- cussed new intervention venues in the public health field. The authors first talk about the Internet as a risk environment, followed by the opportunities for pre- vention intervention that it provides. Following is the chapter on male con- doms by Warner and Stone, with the latest data on condom efficacy and implications for prevention strategies. The field of vaccines for STIs is the sub- ject of the last chapter in Part 2. While only two STI vaccines have been approved for use (HBV and HPV), both present enormous opportunities and challenges in the behavioral realm.

Part 3 shifts focus from intervention types to specific population groups.

Public health practitioners have long understood that how one uses interven- tions must be tailored to the particular characteristics and culture of the tar- geted group. All population groups in Part 3 are considered at high risk for STDs. The first chapter by Ethier and Orr focuses on adolescents, the age group with highest vulnerability to STDs. The next chapter by McCree and Rompalo is about particular issues related to women, who bear the greatest burden from the sequelae of untreated STDs. The HIV/AIDS epidemic has brought to light the high-risk behaviors of MSM. The MSM population is likewise at high risk for other STDs, the topic of a chapter by Fenton and xvi Introduction

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Bloom. Leichliter et al. focus on persons who have repeat STIs. “Repeaters”

have an increased risk for sequelae and may be members of a core group of people who continue to spread disease in a community. Thus, this population requires unique approaches to interventions, which are discussed in Leichliter et al.’s chapter. Williams and Kahn address the unique risks and opportunities for prevention in incarcerated populations. The authors not only review the STD burden on this population, but also discuss how the related contextual factors associated with incarceration and the effects of such imprisonment on the individual impact efforts to prevent STI transmission.

Finally, the STD burden of illicit drug users and the barriers to prevention they face are addressed in the chapter by Semaan et al. Based on the limited body of available research related to STD prevention in this population, this chapter concentrates on STD prevention and control activities specific to heterosexual drug users.

To provide some insight as to how behavioral research is conducted, Part 4 is intended to help the reader understand methods. The first chapter, by McFarlane and St. Lawrence, describes several different forms of measurement and how to determine whether they are “accurate.” The chapter by Gorbach and Galea out- lines the main types of qualitative research approaches and how they are applied to STD prevention research. Chapel and Seechuk write about evaluation and its importance for improvement of programs. Specific examples from the STD pre- vention field are incorporated to demonstrate the utility of evaluation. Following is a chapter on a specific evaluation tool, cost-effectiveness analysis (CEA) by Gift and Marrazzo. The chapter introduces CEA and its limitations, followed by its important role in analyzing STD interventions. Rietmeijer and Gandelman take on the important field of research translation. They discuss the critical importance not only of understanding model behavioral interventions that work, but also of putting into practice the best methods to disseminate and adopt interventions.

The final part of the book addresses two disciplines not unique to STD pre- vention or public health. The first by Semaan and Leinhos is about ethical con- siderations in public health practice as they apply to STD prevention interventions. Key concepts in the ethics literature are described as a basis for looking at ethical issues that arise in STD prevention and control. The last chapter by Zenilman considers STD prevention-related policy and its interface with science. The topic is discussed in the context of core public health func- tions—assessment, assurance, policy development, and communication.

Though choices for and insights about behavioral interventions for STDs continue to grow, the chapters that follow provide a comprehensive summary of what we know to date. We hope this volume will serve as a stimulating and useful guide to the rich world of social and behavioral parameters for STD prevention.

Acknowledgment: The authors wish to thank Partricia Jackson for her outstand- ing support in the preparation of this manuscript.

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xviii Introduction

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16. Pinkerton S. Cost Effectiveness Trials in HIV Prevention Studies. Lecture presented at the CFAR Social and Behavioral Sciences Research Network (SBSRN). First National Scientific Meeting, October 11, 2006, Philadelphia, PA.

17. Farmer PE. Help Us Help Them Donation Presentation: Boston Health Care for the Homeless Program. Opening Session, American Public Health Association (APHA).

134th Annual Meeting, November 5, 2006, Boston, MA.

18. Aral SO, Padian NS, Holmes KK. Advances in multilevel approaches to under- standing the epidemiology and prevention of sexually transmitted infections and HIV: An overview. Journal of Infectious Diseases. 2005;191:S1–S6.

19. Wasserheit JN, Aral SO. The dynamic topology of sexually transmitted disease epidemics: Implications for prevention strategies. Journal of Infectious Diseases.

1996;174:S201–S213.

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20. Garnett GP. The geographical and temporal evolution of sexually transmitted dis- ease epidemics. Sexually Transmitted Infections. 2002;78:i14–i19.

21. Blanchard JF. Populations, pathogens, and epidemic phases: Closing the gap between theory and practice in the prevention of sexually transmitted diseases.

Sexually Transmitted Infections. 2002;78:i183–i188.

22. Garnett GP. Intervention impacts dependence on socio-epidemiologic context and target groups. International Journal of STD & AIDS. 2006;17:6–7.

23. Aral SO. Determinants of STD epidemics: Implications for phase appropriate inter- vention strategies. Sexually Transmitted Infections. 2002;78:i1–i2.

24. Anderson RM, May RM. Infectious Diseases of Humans: Dynamics and Control.

Oxford: Oxford University Press; 1991.

Introduction xix

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xxi

About the Editors

Sevgi O. Aral, Ph.D., is the Associate Director for Science at the Division of STD Prevention, National Centers for HIV, STD, and TB Prevention at the Centers for Disease Control and Prevention, where she is responsible for the oversight and direction of all scientific activities including the intramural and extramural research programs and science program interactions. Her work has focused on risk and preventive behaviors, gender differences, societal charac- teristics that influence STD and HIV rates, contextual issues, and effects of dis- tinct types of sexual mixing on STD spread. Her research has been in both domestic and international settings, and her writings have included cross- cultural comparative analyses. Dr. Aral has served on the editorial boards of several scientific journals including Sexually Transmitted Diseases, AIDS Education and Prevention, Sexually Transmitted Infections, AIDS, and American Journal of Public Health. In addition, she is an associate editor of Sexually Transmitted Diseases and Sexually Transmitted Infections. She is the recipient of the 2006 Thomas Parran Award, which is given for lifetime achievement by the American STD Association. Dr. Aral received her Ph.D. and M.A. degrees in social psychology from Emory University and another M.A. degree in demography from the University of Pennsylvania. She completed her under- graduate training at Middle East Technical University in Turkey.

John M. Douglas, Jr., M.D., is Director of the Division of STD Prevention, National Centers for HIV, STD, and TB Prevention at the Centers for Disease Control and Prevention (CDC), where he is responsible for developing and directing CDC’s national STD prevention programs as well as related behav- ioral, epidemiologic, surveillance, laboratory, health services, and evaluation research. Dr. Douglas brings more than 25 years of experience and leadership in the field of STD prevention to his role as Director. Prior to joining CDC in 2003, Dr. Douglas served in a combination of key management, science, and medical positions for the Denver Department of Health and Hospitals (now Denver Health). These included Director of STD Control; Director, Denver Public Health Virology Laboratory; Attending Physician in Medicine and Infectious Diseases; and Director, Denver STD Prevention Training Center. He also served on the faculty of the University of Colorado Health Sciences as Professor in the departments of Medicine and Preventive Medicine and

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Biometrics. He is a significant contributor to the field of STD/HIV prevention, particularly viral STD, with over 100 scholarly articles in peer-reviewed jour- nals and book chapters. In addition, he has served on the editorial boards of several scientific journals, including Sexually Transmitted Diseases. He is a member of the Infectious Disease Society of America, the American STD Association, the American Public Health Association, and the American College of Physicians. Dr. Douglas earned his B.A. degree in English, summa cum laude, from Davidson College, North Carolina, in 1974 and his M.D.

degree from Harvard Medical School in 1978.

Judith A. Lipshutz, M.P.H., currently works at the Centers for Disease Control and Prevention (CDC) in the Office of the Associate Director for Science, Office of the Director, Division of STD Prevention, National Centers for HIV, STD, and TB Prevention. She serves as a central communicator to the nation’s public health STD prevention community of the latest research pub- lished in peer-reviewed journals and manages the editing of major DSTDP publications. Since 1996, she has coordinated the National STD Prevention Conference, the premier domestic STD prevention meeting where scientific and programmatic leaders converge every other year. For 7 years, she served as the chief of the Communications and External Relations Office during which time she coordinated CDC’s National STD Prevention Partnership as well as policy and communication efforts for the Division. Prior to coming to CDC, she spent over 11 years as the Project Director for AIDS Initiatives and the Venereal Disease Action Coalition at United Community Services in Detroit, where she initiated and oversaw the city’s largest AIDS case manage- ment system. Earlier, she coordinated adolescent health services at a migrant health center in south Texas. Ms. Lipshutz received her B.A. degree from Mt.

Holyoke College in 1975 and her M.P.H. degree from the University of Michigan in 1980.

xxii About the Editors

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xxiii

Contents

Foreword . . . . v

Introduction . . . . ix

About the Editors . . . . xxi

Contributors . . . xxvii

Part 1 Overview Chapters: Behavioral Interventions Chapter 1 History of Behavioral Interventions in STD Control . . . 3

Laura J. McGough and H. Hunter Handsfield Chapter 2 Behavioral Interventions for STDs: Theoretical Models and Intervention Methods . . . 23

Janet S. St. Lawrence and J. Dennis Fortenberry Chapter 3 Biomedical Interventions . . . 60

Stuart Berman and Mary L. Kamb Part 2 Intervention Approaches Chapter 4 Dyadic, Small Group, and Community-Level Behavioral Interventions for STD/HIV Prevention . . . 105

Donna Hubbard McCree, Agatha Eke, and Samantha P. Williams Chapter 5 Structural Interventions . . . 125

Frederick R. Bloom and Deborah A. Cohen Chapter 6 STD Prevention Communication: Using Social Marketing Techniques with an Eye on Behavioral Change . . . 142 Miriam Y. Vega and Khalil G. Ghanem

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xxiv Contents

Chapter 7

Partner Notification and Management Interventions . . . 170 Matthew Hogben, Devon D. Brewer, and Matthew R. Golden

Chapter 8

Interventions in Sexual Health Care–Seeking and Provision

at Multiple Levels of the U.S. Health Care System . . . 190 Matthew Hogben and Lydia A. Shrier

Chapter 9

Use of the Internet in STD/HIV Prevention . . . 214 Mary McFarlane and Sheana S. Bull

Chapter 10

Male Condoms . . . 232 Lee Warner and Katherine M. Stone

Chapter 11

STI Vaccines: Status of Development, Potential Impact,

and Important Factors for Implementation . . . 248 Nicole Liddon, Gregory D. Zimet, and Lawrence R. Stanberry

Part 3 Interventions by Population Chapter 12

Behavioral Interventions for Prevention and Control

of STDs Among Adolescents . . . 277 Kathleen A. Ethier and Donald P. Orr

Chapter 13

Biological and Behavioral Risk Factors Associated with STDs/HIV

in Women: Implications for Behavioral Interventions . . . 310 Donna Hubbard McCree and Anne M. Rompalo

Chapter 14

STD Prevention with Men Who Have Sex with

Men in the United States . . . 325 Kevin A. Fenton and Frederick R. Bloom

Chapter 15

STD Repeaters: Implications for the Individual and

STD Transmission in a Population . . . 354 Jami S. Leichliter, Jonathan M. Ellen, and Robert A. Gunn

Chapter 16

Looking Inside and Affecting the Outside: Corrections-Based

Interventions for STD Prevention . . . 374 Samantha P. Williams and Richard H. Kahn

Chapter 17

STDs Among Illicit Drug Users in the United States:

The Need for Interventions . . . 397 Salaam Semaan, Don C. Des Jarlais, and Robert M. Malow

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Part 4 Understanding Methods Chapter 18

Quantitative Measurement . . . 433 Mary McFarlane and Janet S. St. Lawrence

Chapter 19

Qualitative Methods . . . 447 Pamina M. Gorbach and Jerome Galea

Chapter 20

From Data to Action: Integrating Program Evaluation

and Program Improvement . . . 466 Thomas J. Chapel and Kim Seechuk

Chapter 21

Cost-Effectiveness Analysis . . . 482 Thomas L. Gift and Jeanne Marrazzo

Chapter 22

From Best Practices to Better Practice: Adopting Model Behavioral

Interventions in the Real World of STD/HIV Prevention . . . 500 Cornelis A. Rietmeijer and Alice A. Gandelman

Part 5 Ethical and Policy Issues Chapter 23

The Ethics of Public Health Practice for the Prevention

and Control of STDs . . . 517 Salaam Semaan and Mary Leinhos

Chapter 24

Policy and Behavioral Interventions for STDs . . . 549 Jonathan M. Zenilman

Index . . . 569

Contents xxv

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xxvii

Contributors

Sevgi O. Aral, Ph.D.

Division of STD Prevention, National Centers for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA

Stuart Berman, M.D., Sc.M.

Division of STD Prevention, National Centers for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA

Frederick R. Bloom, R.N., Ph.D.

Division of STD Prevention, National Centers for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA

Devon D. Brewer, Ph.D.

Interdisciplinary Scientific Research, Seattle, Washington, USA

Sheana S. Bull, Ph.D., M.P.H.

University of Colorado Health Sciences Center, Denver, Colorado, USA

Thomas J. Chapel, M.A., M.B.A.

Office of the Director/Office of Strategy and Innovation, Centers for Disease Control and Prevention, Atlanta, Georgia, USA

Deborah A. Cohen, M.D., M.P.H.

RAND Center for Population Health and Health Disparities, Santa Monica, California, USA

Don C. Des Jarlais, Ph.D.

Beth Israel Medical Center and Narcotic and Drug Research Institutes, New York, New York, USA

John M. Douglas, Jr., M.D.

Division of STD Prevention, National Centers for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA

Agatha Eke, Ph.D.

Division of HIV/AIDS Prevention, National Centers for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA

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Jonathan M. Ellen, M.D.

Division of General Pediatrics and Adolescent Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA

Kathleen A. Ethier, Ph.D.

Division of STD Prevention, National Centers for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA

Kevin A. Fenton, M.D., Ph.D.

National Centers for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA

J. Dennis Fortenberry, M.D., M.S.

Indiana University School of Medicine, Indianapolis, Indiana, USA

Jerome Galea, M.S.W.

Department of Epidemiology, School of Public Health, University of California, Los Angeles, California, USA

Alice A. Gandelman, M.P.H.

California STD/HIV Prevention Training Center, STD Control Branch, California Department of Health Services, Oakland, California, USA

Khalil G. Ghanem, M.D.

Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA

Thomas L. Gift, Ph.D.

Division of STD Prevention, National Centers for HIV, STD, and TB

Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA

Matthew R. Golden, M.D., M.P.H.

STD Control Program for Public Health–Seattle and King County and Harborview Medical Center, University of Washington School of Medicine, Seattle, Washington, USA

Pamina M. Gorbach, M.H.S., Dr.P.H.

Department of Epidemiology, School of Public Health, University of California, Los Angeles, California, USA

Robert A. Gunn, M.D., M.P.H.

Public Health Services Division, San Diego County Health and Human Services, San Diego, California, USA

H. Hunter Handsfield, M.D.

Battelle Centers for Public Health Research and Evaluation and University of Washington School of Medicine, Seattle, Washington, USA

Matthew Hogben, Ph.D.

Division of STD Prevention, National Centers for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA xxviii Contributors

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Edward W. Hook III, M.D.

University of Alabama at Birmingham School of Medicine and Jefferson County Department of Health, Birmingham, Alabama, USA

Richard H. Kahn, M.S.

Division of Parasitic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA

Mary L. Kamb, M.D., M.P.H.

Division of STD Prevention, National Centers for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA

Jami S. Leichliter, Ph.D.

Division of STD Prevention, National Centers for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA

Mary Leinhos, Ph.D.

National Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA

Nicole Liddon, Ph.D.

Division of STD Prevention, National Centers for HIV, STD, and TB

Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA

Judith A. Lipshutz, M.P.H.

Division of STD Prevention, National Centers for HIV, STD, and TB

Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA

Robert M. Malow, Ph.D., A.B.P.P.

Florida International University, Miami, Florida, USA

Jeanne Marrazzo, M.D., M.P.H.

Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle, Washington, USA

Donna Hubbard McCree, Ph.D., M.P.H., R.Ph.

Division of HIV/AIDS Prevention, National Centers for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA

Mary McFarlane, Ph.D.

Division of STD Prevention, National Centers for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA

Laura J. McGough, Ph.D.

Department of History of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA

Donald P. Orr, M.D.

Indiana University School of Medicine, Indianapolis, Indiana, USA

Contributors xxix

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Cornelis A. Rietmeijer, M.D., Ph.D.

STD Control Program, Denver Public Health Department and University of Colorado at Denver and Health Sciences Center, Denver, Colorado, USA

Anne M. Rompalo, M.D., Sc.M.

Johns Hopkins University School of Medicine, Baltimore, Maryland, USA

Kim Seechuk, M.P.H.

Division of STD Prevention, National Centers for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA

Salaam Semaan, Dr.P.H.

National Centers for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA

Lydia A. Shrier, M.D., M.P.H.

Division of Adolescent/Young Adult Medicine, Children’s Hospital Boston and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA

Lawrence R. Stanberry, M.D., M.P.H.

Sealy Center for Vaccine Development, University of Texas Medical Branch, Galveston, Texas, USA

Janet S. St. Lawrence, Ph.D.

Mississippi State University–Meridian Campus, Meridian, Mississippi, USA

Katherine M. Stone, M.D.

Atlanta, Georgia, USA

Miriam Y. Vega, Ph.D.

Latino Commission on AIDS, New York, New York, USA

Lee Warner, Ph.D., M.P.H.

Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA

Samantha P. Williams, Ph.D.

Division of STD Prevention, National Centers for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA

Jonathan M. Zenilman, M.D.

Infectious Diseases Division, Johns Hopkins University Bayview Medical Center, Baltimore, Maryland, USA

Gregory D. Zimet, Ph.D.

Indiana University Cancer Center and Medical School, Indianapolis, Indiana, USA

xxx Contributors

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