The STI/HIV epidemic affects African-American adolescents disproportionately and requires intervention efforts at the community and individual level. Community-based STI screening and counseling has the potential to address structural barriers that African Americans confront and might also serve to detect and avert the spread of asymptomatic STIs [13
]. From an individual's perspective, an STI-positive diagnosis with subsequent medical care and counseling has the potential to be a powerful intervention reinforcing the need for protective behavior while also treating infection.
This study found strong evidence that adolescents who tested positive for an STI in a community-based STI-screening program and received CDC-compliant treatment and counseling decreased their number of sex partners. We also found a decrease in unprotected sex among STI-positive adolescents.
Our results also showed that a positive STI test result was associated with partner reduction at 3 and 6 months, whereas a reduction in unprotected sex was evident only at the 6 month assessment. One interpretation of this difference is that while STI-positive participants may well have reduced the number of partners soon after learning of their infection (either by dissolving these relationships or discontinuing sex with those partners), they continued to engage in unprotected sex with the partners they retained. However, by the 6-month assessment, they may have acquired new partners with whom they were likely to use condoms at the same rate as STI-negative youth. Thus, the reduction in unprotected sex that was observed at 6 months may be a delayed effect that took longer to appear than the more immediate effect on number of partners. We do not have direct evidence to support this hypothesis; however, it is consistent with what we know about the short course of sexual relationships in adolescents [32
] and condom use behaviors with new partners [33
]. This finding also underscores the need for further research on the effects of community-based STI screening on condom use with new and ongoing partners.
Despite decreased sexual risk behavior, 8 of 42 adolescents who tested positive at baseline (19%) were re-infected at 6-month follow-up. Similar re-infection rates have been found in other studies [34
]. In addition to inadequate reduction in risk behavior and treatment failure, re-infection may reflect inadequate treatment and counseling of partners. Indeed, re-infection is common due to continued sexual contact with untreated partners [35
]. Although patient-initiated partner notification is central to most STI control efforts [26
], prior research suggests that fewer than 40% of partners of STI-positive adolescents are reached [37
]. Although our data do not allow for analysis of the effect of STI screening at the partner level, the 19% re-infection rate suggests that partner notification warrants more effective strategies and research attention.
An alternative explanation for the decrease in risky sexual behavior in STI-positive adolescents is that it reflects regression to the mean [38
]. According to this explanation, a positive test result at baseline was a marker for an extreme event. However, regression to the mean would lead this group to regress at the 3-month assessment, but not at 6 months as observed. Furthermore, the infection rate at 6 months was higher in the group that tested positive at baseline than those who tested negative (19 vs. 4.3%), indicating that an STI test result at baseline was not a chance event.
Although demonstrating beneficial effects for STI-positive adolescents, we observed no reduction in number of sex partners or unprotected sex for STI-negative adolescents. Indeed, after receiving a negative test result, adolescents exhibited increases in risk behavior but these were typical of maturation. Although these results suggest that receiving a negative STI test does not cause adverse effects, they underscore the need for counseling of STI-negative youth to reduce the normal age trajectory of risky sexual behavior.
The small group HIV-prevention intervention implemented in this study did not reduce sexual risk behaviors. However, previously reported analyses using data from the current cities as well as data from two other cities receiving an STI/HIV prevention media campaign [21
] indicate that the media campaign led to improved self-efficacy and safe sex attitudes and expectancies among STI negative and positive adolescents. The media also reduced unprotected sex but not number of partners. These results, combined with the results from the current study, suggest that a media campaign coupled with community-based STI screening might be particularly successful as it has the potential to reduce sexual risk behavior in both STI-positive and STI-negative youth, something that STI screening alone does not achieve.
Limitations and directions for future studies
Several limitations need to be acknowledged. First, we included only a 6 month follow-up period; although this is longer than previous research, future studies might examine effects over longer time periods. Second, we do not have detailed information about the quality of counseling provided to STI-positive youth. We did, however, select health care providers who were experienced and well-respected in the community for treating STIs in African American adolescents. We also contacted the two health care providers after they completed the baseline and 6 month STI treatments and verified that counseling had been delivered according to CDC guidelines. Indeed, we found strong effects of receiving an STI test suggesting that, even in an uncontrolled setting in which counseling was not monitored, it was efficacious. In addition, our findings were robust across regions. However, quality of service delivery should be confirmed in future research. Third, we did not examine the effects of testing and counseling separately; this is difficult to do given the ethical and clinical mandates associated with public health practice.
A fourth limitation is that we were unable to disentangle the effects of screening and participation in the small group interventions. Although no differences in sexual risk behavior were observed between participants in the HIV and general health group interventions, it is possible that the effects of the positive STI test result are partly attributable to receiving a small group intervention. Future studies should examine the potential effects of additional counseling that goes beyond standard care for positive STI test results. Fifth, because of the absence of a 6-month incidence rate among youth who were not screened, we could not identify screening effects on overall STI incidence in our sample. This would be challenging, however, because a design with a control arm in which persons are not tested at baseline does not allow for a true test of reduction in STI incidence, that is, it only permits a comparison between an incidence rate (screening arm) and a prevalence rate (control arm). Sixth, the use of self-report introduces the possibility of memory or motivational biases; however, our use of ACASI helped to minimize such biases [22
]. Finally, it should also be noted that STI screening is expensive and would require new funding mechanisms, especially if administered by most CBOs.