This review assessed HIV risk reduction interventions for adolescents. The authors concluded that there was considerable evidence for the effectiveness of these interventions but, owing to methodological limitations of the available research, there is a need to improve the quality of primary research in this area, a conclusion that seems justified.
To provide a review and methodological critique of human immunodeficiency virus (HIV) risk reduction interventions for adolescents.
PsycINFO, AIDSLINE, MEDLINE and CINAHL were searched up to September 2000; the search terms were reported. Reference sections from empirical articles and reviews were also checked. Only studies published in peer-reviewed journals were eligible for inclusion.
Randomised controlled trials (RCTs) were eligible for inclusion.
No specific inclusion criteria for the interventions were reported. The multi-component interventions evaluated in the review included group discussions, counselling, communication and negotiation skills, pamphlets on sexually transmitted diseases (STDs), goal setting, social and self-rewards, education, HIV and youth speakers, problem-solving, self-management, cognitive skills training, modelling behavioural rehearsal with feedback, role-play, skills training, story telling, videos and games. Studies evaluating interventions designed to increase the rate of HIV testing were not included in the review unless specific sexual risk reduction outcomes were reported. The interventions were conducted in schools, community sites and health care settings.
Studies primarily of teenagers with a mean age of 19 years or less, or an age range within 13 to 19 years, were eligible for inclusion. The participants included in the review were aged from 9 to 20 years. The sample size of the included studies varied greatly, ranging from 34 to 3,869. The review included studies of both general and high-risk populations. Only one study was conducted with homosexual teenagers.
Studies assessing sexual behaviour risks such as frequency of unprotected sex and condom use were eligible for inclusion. The included studies reported on condom use, the incidence and treatment of STDs, the frequency of sex (protected and unprotected), the number of partners, delayed onset of sex, and abstinence.
The authors did not state how the papers were selected for the review, or how many reviewers performed the selection.
The authors critiqued the literature using six methodological features: use of theory, intervention content and format, measurement, study design, and data analysis. The authors did not state how the papers were assessed for validity, or how many reviewers performed the validity assessment.
The authors did not state how the data were extracted for the review, or how many reviewers performed the data extraction.
The studies were combined in a narrative.
Differences between the studies in terms of methodology were explored. This included their use of theory, intervention content and format, measurement, study design and data analysis.
Twenty-two RCTs (23 comparisons) were included in the review (n=5,356).
Sixteen studies evaluated group interventions, with the number of sessions ranging from 1 to 12. Seven evaluated individual interventions, six with a single session and one with five sessions. Of the 23 interventions, 13 achieved a statistically significant reduction in risk.
Eight studies (4 individual, 4 group) reported on the contraction of STDs, which was reduced in 29% of the studies (1 individual, 1 group).
Fifteen studies (5 individual, 10 group) reported on the number of partners, which was reduced in 27% of the studies (1 individual, 3 group).
Fifteen studies (6 individual, 9 group) reported on condom use, which improved in 53% of the studies (2 individual, 6 group).
Seven studies (1 individual, 7 group) reported on the frequency of unprotected sex, which was reduced in 75% of the studies (6 group).
Seven studies (2 individual, 5 group) reported on abstinence, which increased by 14% in one study (a group intervention of 8 sessions).
Four group intervention studies reported on delayed onset of sex, which increased in 50% of the studies.
Twelve studies (intervention types unclear) reported on the frequency of sex, which was reduced by 42%.
There was considerable evidence for the efficacy and effectiveness of HIV prevention programmes for adolescents. The authors also concluded that there was a need to improve the methodology of research in this area.
The review question was defined in terms of the participants, study design and outcomes. Several relevant electronic databases were searched and the search terms reported. Only publications in peer-reviewed journals were considered, and it was not reported whether language restrictions had been applied. These factors may lead to the introduction of language and publication bias, which the authors themselves did not investigate. The authors did not report how the study selection, data extraction or validity assessment processes were carried out, thus precluding an assessment of the methodological rigour of the review.
Given the heterogeneity of the included studies, the decision not to combine the studies in a meta-analysis was appropriate. The authors' conclusion, that there is a need to improve the quality of primary research in this area, appears to be justified given the methodological limitations of the available research.
Practice: The authors did not state any implications for practice.
Research: The authors stated that more research is needed to compare individual and group approaches to HIV prevention, and to develop effective brief, single-session, individualised interventions. The authors also recommended consistent reporting of effect sizes and the discussion of clinically meaningful intervention effects to assist comparisons across studies.
National Institute of Mental Health, grant numbers F31-MH12740 and K02-MH01582.
This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.