Behavioral interventions to prevent HIV and other STIs
Behavioral interventions to prevent HIV and other sexually transmitted infections (STIs) aim to improve healthy behavior, psychosocial functioning, and quality of life through individual-level, group-level, and community-level interventions. Interventions at all levels involve education; individual and group-level interventions may also include training and support. Group-level intervention activities and information can be reinforced with peer pressure. Community-level interventions often focus both on sharing information and changing social norms within the target community1.
What could this strategy improve?
Expected Benefits
Our evidence rating is based on the likelihood of achieving these outcomes:
Reduced incidence of STIs
Reduced risky sexual behavior
Increased condom use
What does the research say about effectiveness?
There is strong evidence that behavioral interventions to reduce HIV and other sexually transmitted infections (STIs) decrease sexual risk behaviors2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12,1, increase condom use1, 5, 7, 12, 13, 14, 15, 16, 17, 18, and decrease STI incidence2, 5, 7, 9, 10, 11, 12, 15, 17, 18.
Behavioral interventions are effective when implemented on the individual-, group-, and community-level1, 2. They are effective in a variety of settings, including primary care1, 2, 8, 16, STI clinics2, 11, and schools7. Such interventions have been shown to decrease risky sexual behaviors and STI incidence among men who have sex with men1, 4, 6, 8, 12, 19, people who are heterosexual12, Black10, 11, 14, 20, 21, 22, or Hispanic11, as well as high-risk groups such as STI patients, people living with HIV, and people who use drugs2, 11, 12. These interventions also appear to decrease STI incidence2, 17 and risky sexual behaviors among adolescents7, 16, 17, 23 and women of color with low incomes15.
The effects of behavioral interventions appear strongest among men who have sex with men, individuals who are HIV-positive, and Hispanics12. Behavioral interventions are more effective when culturally tailored5, 10, 11, 20, 22, 24, 25 or delivered by individuals who have similar identities to participants1, 10, 11, 21, 24. Interventions that include multiple sessions appear to be more effective than single sessions1, 22, 25, though single session interventions can be effective as well3, 26. Longer counseling sessions of at least two hours appear to be more effective, though shorter sessions can also reduce STI incidence2.
Interventions that incorporate skills building, such as proper condom use or negotiating safer sex, appear to be more effective than those that do not include skills building components1, 5, 6, 9, 11, 13, 22. Providing medical services or referrals may increase the effectiveness of behavioral interventions for Black men and men who were formerly incarcerated21.
How could this strategy advance health equity? This strategy is rated potential to decrease disparities: suggested by intervention design.
Behavioral interventions to reduce HIV and other STIs have the potential to decrease disparities in HIV and STI incidence, if they are designed for those most at risk of HIV and STI infection. Inequalities by gender, race, geographic location, and economic status persist in HIV diagnosis and care30. STIs disproportionately affect racial and sexual minority groups. In 2021, almost a third of chlamydia, gonorrhea, and syphilis infections were diagnosed in Black individuals, and men who have sex with men were diagnosed with around a third of gonorrhea cases and almost half of syphilis infections31. In 2019, 29% of new HIV infections were among Hispanic/Latino individuals32 and 26% of new HIV infections were in Black gay and bisexual men33. Young Black men who have sex with men are at particularly high-risk for contracting HIV34. Hispanic women are four times more likely to contract HIV than women who are white35.
Available evidence suggests that behavioral interventions have been effective for Black and Hispanic men and women4, 20, 21, 34, 35, STI clinic patients11, and men who have sex with men4, 6, 12, 19, 34.
Tailoring interventions for specific groups appear to increase the effectiveness of the intervention24, and culturally tailored interventions can be more effective5, 10, 11, 12, 20, 22, 25. For example, women of color appear to benefit more from culturally grounded, group-based interventions that take place over multiple sessions25. For Hispanic women, use of lay health advisors, culturally appropriate narratives, and incorporating the Theory of Gender and Power have been successfully used to address cultural factors35.
Interventions specifically addressing racial and ethnic disparities in HIV prevention are relatively new36. More research is needed to understand the effectsof behavioral intervention among vulnerable and understudied populations like young men who have sex with men, particularly those who are also Black, homeless, incarcerated or in foster care34. Additional research is needed on how best practices should be tailored for specific populations such as women of color, Black young men who have sex with men, and heterosexual Black men20, 21, 34, 35.
What is the relevant historical background?
Sexually transmitted infections (STIs) have carried stigma for centuries, shaped by negative views of poverty, women, and sex37. STIs are associated with promiscuity and deviant behavior for women, while STIs in men are treated merely as a medical condition38. Stigma has continued to shape how STIs are studied, diagnosed, and treated. The racist and unethical Tuskegee Syphilis Study, administered by the federal government, intentionally withheld syphilis treatment from Black men for decades without their knowledge, to study the natural course of the disease, ultimately sowing widespread mistrust of health systems and medical research39.
When the AIDS epidemic began, federal response was slow to acknowledge and respond to it, in part because it primarily affected gay men in a time when many states still criminalized homosexuality. While the first case of HIV/AIDS in the U.S. was reported in 198140, 41, major federal funding wasn’t allocated until 198541. HIV criminalization laws were passed in many states criminalizing behavior such as non-disclosure, exposure, and/or transmission of HIV, or increasing sentence length for crimes based on someone’s HIV status42, long before pharmaceuticals were available to treat or prevent transmission43. Today, HIV criminalization unjustly applies criminal law to nonmalicious behavior by people living with HIV and the laws are disproportionately applied to people from groups who have been marginalized44, While 13 states have repealed or modernized their HIV criminalization laws, 34 states still have HIV/STI/communicable disease criminalization laws in place in 2023. Such laws can carry penalties up to life in prison42.
State and federal funding are important to address the rising incidence of STIs, however, historical trends show that funding has stagnated45.
Equity Considerations
- Who is currently providing behavioral interventions in your community? How are the interventions tailored to reflect the cultures of people in your community?
- How does stigma, and other systematic barriers, prevent people from accessing behavioral interventions in your community? What additional strategies can be implemented to overcome those barriers?
- Who already has access to your program? Are there certain groups in your community that would benefit from a behavioral intervention to prevent and reduce HIV/STI that currently are not involved?
Implementation Examples
Implementation Resources
‡ Resources with a focus on equity.
Follins 2017‡ - Follins LD, Dacus J. Conceptualizing and developing behavioral HIV prevention interventions for Black gay men. Journal of HIV/AIDS & Social Services. 2017;16(1):75-88.
CDC-STDs Effective Interventions‡ - Centers for Disease Control and Prevention (CDC). Sexually Transmitted Diseases (STDs). Effective interventions: Reviews of specific intervention strategies.
CDC-Prevent HIV - Centers for Disease Control and Prevention (CDC). HIV: Effective interventions. Prevent: Behavioral, biomedical, and structural interventions.
NNCPTC-BPTC - National Network of STD Clinical Prevention Training Centers (NNCPTC). Behavioral Prevention Training Centers (BPTC): courses that teach the use of evidence-based STD/HIV prevention interventions at the individual, group, and community level.
Footnotes
* Journal subscription may be required for access.
1 CG-HIV risk reduction MSM - The Guide to Community Preventive Services (The Community Guide). The effectiveness of individual-, group-, and community-level HIV behavioral risk reduction interventions for adult men who have sex with men: A systematic review.
2 Henderson 2020 - Henderson JT, Senger CA, Henninger M, et al. Behavioral counseling interventions to prevent sexually transmitted infections: Updated evidence report and systematic review for the U.S. Preventive Services Task Force. JAMA - Journal of the American Medical Association. 2020;324(7):682-699.
3 Sagherian 2016 - Sagherian MJ. Single-session behavioral interventions for sexual risk reduction: A meta-analysis. Annals of Behavioral Medicine. 2016;50(6):920-934.
4 Perez 2018 - Pérez A, Santamaria EK, Operario D. A systematic review of behavioral interventions to reduce condomless sex and increase HIV testing for Latino MSM. Journal of Immigrant and Minority Health. 2018;20(5):1261-1276.
5 von Sadovszky 2014 - von Sadovszky V, Draudt B, Boch S. A systematic review of reviews of behavioral interventions to promote condom use. Worldviews on Evidence-Based Nursing. 2014;11(2):107–17.
6 Lorimer 2013 - Lorimer K, Lawrence M, McPherson K, Cayless S, Cornish F. Systematic review of reviews of behavioural HIV prevention interventions among men who have sex with men. AIDS Care. 2013;25(2):133-150.
7 Chin 2012 - Chin HB, Sipe TA, Elder R, et al. The effectiveness of group-based comprehensive risk-reduction and abstinence education interventions to prevent or reduce the risk of adolescent pregnancy, Human Immunodeficiency Virus, and sexually transmitted infections: Two systematic reviews for the Guide to Community Preventive Services. American Journal of Preventive Medicine. 2012;42(3):272-294.
8 Cochrane-Johnson 2008 - Johnson WD, Diaz RM, Flanders WD, et al. Behavioral interventions to reduce risk for sexual transmission of HIV among men who have sex with men. Cochrane Database of Systematic Reviews. 2008;(3):CD001230.
9 Wetmore 2010 - Wetmore CM, Manhart LE, Wesserheit JN. Randomized controlled trials of interventions to prevent sexually transmitted infections: Learning from the past to plan for the future. Epidemiologic Reviews. 2010;32(1):121-36.
10 Crepaz 2009 - Crepaz N, Marshall KJ, Aupont LW, et al. The efficacy of HIV/STI behavioral interventions for African American females in the United States: A meta-analysis. American Journal of Public Health. 2009;99(11):2069-78.
11 Crepaz 2007 - Crepaz N, Horn AK, Rama SM, et al. The efficacy of behavioral interventions in reducing HIV risk sex behaviors and incident sexually transmitted disease in black and hispanic sexually transmitted disease clinic patients in the United States: A meta-analytic review. Sexually Transmitted Diseases. 2007;34(6):319-332.
12 Noar 2008 - Noar SM. Behavioral interventions to reduce HIV-related sexual risk behavior: Review and synthesis of meta-analytic evidence. AIDS and Behavior. 2008;12(3):335-353.
13 Gause 2018 - Gause NK, Brown JL, Welge J, Northern N. Meta-analyses of HIV prevention interventions targeting improved partner communication: effects on partner communication and condom use frequency outcomes. Journal of Behavioral Medicine. 2018;41(4):423-440.
14 Evans 2020 - Evans R, Widman L, Stokes MN, et al. Association of sexual health interventions with sexual health outcomes in Black adolescents: A systematic review and meta-analysis. JAMA Pediatrics. 2020;174(7):676-689.
15 Ruiz-Perez 2017 - Ruiz-Perez I, Murphy M, Pastor-Moreno G, Rojas-García A, Rodríguez-Barranco M. The effectiveness of HIV prevention interventions in socioeconomically disadvantaged ethnic minority women: A systematic review and meta-analysis. American Journal of Public Health. 2017;107(12):e13-e21.
16 Cochrane-Shepherd 2011 - Shepherd JP, Frampton GK, Harris P. Interventions for encouraging sexual behaviours intended to prevent cervical cancer. Cochrane Database of Systematic Reviews. 2011;(4):CD001035.
17 Johnson 2011 - Johnson BT, Scott-Sheldon LAJ, Huedo-Medina TB, Carey MP. Interventions to reduce sexual risk for human immunodeficiency virus in adolescents: A meta-analysis of trials, 1985-2008. Archives of Pediatrics & Adolescent Medicine. 2011;165(1):77–84.
18 Scott-Sheldon 2011 - Scott-Sheldon LAJ, Huedo-Medina TB, Warren MR, Johnson BT, Carey MP. Efficacy of behavioral interventions to increase condom use and reduce sexually transmitted infections: A meta-analysis, 1991 to 2010. Journal of Acquired Immune Deficiency Syndromes. 2011;58(5):489-498.
19 O’Donnell 2014 - O’Donnell L, Stueve A, Joseph HA, Flores S. Adapting the VOICES HIV behavioral intervention for Latino men who have sex with men. AIDS and Behavior. 2014;18:767-775.
20 Gilbert 2021 - Gilbert L, Goddard-Eckrich D, Chang M, et al. Effectiveness of a culturally tailored HIV and sexually transmitted infection prevention intervention for Black women in community supervision programs. JAMA Network Open. 2021;4(4):e215226.
21 Henny 2012 - Henny KD, Crepaz N, Lyles CM, et al. Efficacy of HIV/STI behavioral interventions for heterosexual African American men in the United States: A meta-analysis. AIDS and Behavior. 2012;16(5):1092–114.
22 Darbes 2008 - Darbes L, Crepaz N, Lyles C, Kennedy G, Rutherford G. The efficacy of behavioral interventions in reducing HIV risk behaviors and incident sexually transmitted diseases in heterosexual African Americans. AIDS. 2008;22(10):1177-94.
23 Mullen 2002 - Mullen PD, Ramirez G, Strouse D, Hedges LV, Sogolow E. Meta-analysis of the effects of behavioral HIV prevention interventions on the sexual risk behavior of sexually experienced adolescents in controlled studies in the United States. Journal of Acquired Immune Deficiency Syndromes. 2002;30(Suppl 1):S94-105.
24 Covey 2016 - Covey J, Rosenthal-Stott HES, Howell SJ. A synthesis of meta-analytic evidence of behavioral interventions to reduce HIV/STIs. Journal of Behavioral Medicine. 2016;39(3):371-385.
25 Crooks 2019 - Crooks N, Muehrer RJ. Are sexually transmitted infection/HIV behavioral interventions for women of color culturally grounded? A review of the literature. Journal of the Association of Nurses in AIDS Care. 2019;30(5):e64-e81.
26 Eaton 2012 - Eaton LA, Huedo-Medina TB, Kalichman SC, et al. Meta-analysis of single-session behavioral interventions to prevent sexually transmitted infections: Implications for bundling prevention packages. American Journal of Public Health. 2012;102(11):e34–44.
27 NNCPTC-BPTC - National Network of STD Clinical Prevention Training Centers (NNCPTC). Behavioral Prevention Training Centers (BPTC): courses that teach the use of evidence-based STD/HIV prevention interventions at the individual, group, and community level.
28 CDC-STDs Effective Interventions - Centers for Disease Control and Prevention (CDC). Sexually Transmitted Diseases (STDs). Effective interventions: Reviews of specific intervention strategies.
29 CDC-Prevent HIV - Centers for Disease Control and Prevention (CDC). HIV: Effective interventions. Prevent: Behavioral, biomedical, and structural interventions.
30 Taggart 2021 - Taggart T, Ritchwood TD, Nyhan K, Ransome Y. Messaging matters: Achieving equity in the HIV response through public health communication. Lancet HIV. 2021;8(6):e376-e386.
31 CDC-STI Surveillance - Centers for Disease Control and Prevention (CDC). Sexually Transmitted Infections Surveillance.
32 CDC-Hispanic/Latino HIV Incidence - Centers for Disease Control and Prevention (CDC). HIV: HIV by group. HIV and Hispanic/Latino People: HIV Incidence.
33 CDC-African American MSM HIV Incidence - Centers for Disease Control and Prevention (CDC). HIV: HIV by group. HIV and African American Gay and Bisexual Men: HIV Incidence.
34 Hergenrather 2016 - Hergenrather KC, Emmanuel D, Durant S, Rhodes SD. Enhancing HIV prevention among young men who have sex with men: A systematic review of HIV behavioral interventions for young gay and bisexual men. AIDS Education and Prevention. 2016;28(3):252-271.
35 Daniel-Ulloa 2016 - Daniel-Ulloa J, Ulibarri M, Baquero B, et al. Behavioral HIV prevention interventions among latinas in the U.S.: A systematic review of the rvidence. Journal of Immigrant and Minority Health. 2016;18(6):1498-1521.
36 Hemmige 2012 - Hemmige V, McFadden R, Cook S, Tang H, Schneider JA. HIV prevention interventions to reduce racial disparities in the United States: A systematic review. Journal of General Internal Medicine. 2012;27(8):1047-1067.
37 McGough 2005 - McGough LG. HIV/AIDS stigma: Historical perspectives on sexually transmitted diseases. Virtual Mentor: Ethics Journal of the American Medical Association. 2005;7(10):710-715.
38 East 2012 - East L, Jackson D, O’Brien L, Peters K. Stigma and stereotypes: Women and sexually transmitted infections. Collegian. 2012;19(1):15-21.
39 Tobin 2022 - Tobin MJ. Fiftieth anniversary of uncovering the Tuskegee syphilis study: The story and timeless lessons. American Journal of Respiratory and Critical Care Medicine. 2022;205(10):1145-1158.
40 HIV.gov - HIV.gov. HIV and AIDS timeline.
41 Bennington-Castro 2020 - Bennington-Castro J. How AIDS remained an unspoken—but deadly—epidemic for years. History. 2020.
42 CDC HIV-Exposure - Centers for Disease Control and Prevention (CDC). (2023, December 19). HIV and STD criminalization laws. Retrieved October 17, 2024.
43 CDC HIV-Criminalization - Centers for Disease Control and Prevention (CDC). (2023, December 18). HIV criminalization and ending the HIV epidemic. Retrieved September 18, 2024.
44 Bernard 2022 - Bernard, E. J., Symington, A., & Beaumont, S. (2022). Punishing vulnerability through HIV criminalization. American Journal of Public Health, 112(S4), S395–S397.
45 NCSD-STD Funding - National Coalition of STD Directors (NCSD). As STD funding stagnates, rates rise to all-time highs.
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