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Globally, more than 90% of all adolescent and adult HIV infections are transmitted heterosexually. In the United States, approximately 25% of all new HIV diagnoses are in adolescents and young adults (ages 13–24) and this is one of the few age groups in which the HIV infection rates have not decreased. Females are disproportionately impacted by sexual risk behaviors and studies comparing males and females identify disparate factors influencing these behaviors. Research indicates that theoretically-driven, gender tailored interventions can be a more effective approach in HIV prevention. The purpose of this study was to identify and test a theoretically-driven HIV prevention intervention tailored for sexually-active, urban adolescent girls, ages 15-19, the Health Improvement Project for Teens (HIPTeens).
Methods:
A sample of 738 girls recruited from community settings in a northeastern U.S. city were randomized to either a HIV intervention or a structurally equivalent health promotion program. Girls in both groups attended four weekly two-hour sessions and booster sessions at 3 and 6 months. Assessments and behavioral data were collected using Audio Computer-Assisted Self-Interview Software (ACASI) at baseline, and 3, 6 and 12-months post-intervention; we collected biological data for STI testing as well. Following the intervention, girls who received the sexual risk-reduction intervention demonstrated significant reductions in: (a) total episodes of vaginal sex at all follow-ups, (b) number of unprotected vaginal sex acts, and (c) total number of sex partners, as well as (d) a significant increase in sexual abstinence. Medical record audits for a sub-sample of girls (n=322) documented a 50% reduction in positive pregnancy tests.
Results:
The Information-Motivation-Behavioral Skills (IMB) model posits that information and motivation combined with behavioral skills are necessary requisites for behavioral change. We evaluated the utility of the IMB model for guiding interventions to reduce risk in adolescent girls by testing whether HIV-preventive behavior at 6 and 12 months: (a) was a function of an individual’s information about HIV transmission and prevention, motivation to reduce risk, and behavioral skills related to HIV prevention at the 3-month follow-up and (b) and if information and motivation were partially mediated by behavioral skills to influence the initiation and maintenance of HIV preventive behavior.
The IMB model was tested through structural equation modeling utilizing the HIPTeens intervention data. In the model tested, all measurement loadings were highly significant (p < .001). The standardized coefficients and the goodness-of-fit indices (χ2 (223 df) = 459-.95; p = < .001; CFI = .952; RMSEA = .041; 90% CI = .036 - .046) support the relationships among the constructs in the model.
As previously posited, the HIPTeens intervention impacted behavior, unprotected vaginal sex, at 6 and 12 months via the direct effects of behavioral skills. In support of the IMB model, participation in the HIPTeens intervention was shown to directly impact behavioral skills (e.g., condom influence strategies). These short-term behavioral skills at 3 months were related to longer-term behavior changes at 6 months and 12 months post intervention. Condom influence strategies (CISQ) at 3-months were significantly related to the number of vaginal sexual episodes without a condom at 6 months and number of unprotected vaginal sexual episodes at 12 months.
Conclusion:
This study provides evidence for the theoretical relationships posited in the IMB model and the test of their relationships within a HIV prevention RCT. Specifically, IMB behavioral skills were identified as key drivers of longer term behaviorial outcomes. Importantly developing a repertoire of behavioral skills for girls in the intervention group (e.g., negotiation, communication, condom use skills, and avoidance of risk behaviors) were key to actual reduction of risk behavior outcomes in this trial. Results from this study underscore the need to provide theoretically-driven interventions tailored specifically for girls and to develop strategies within these interventions specifically targeting a menu of behavioral options to reduce sexual risk.
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