Project Respect

October 1998

Most Definitive Study to Date on Effectiveness of HIV Counseling and Testing Finds Significant Reduction in Sexually Transmitted Diseases:

Counters Previous Beliefs on Approach to Prevention

A simple change in HIV and STD counseling across the nation could make a tremendous difference in slowing the spread of HIV and other STDs, suggests new data from the Centers for Disease Control and Prevention (CDC). Researchers found that when counselors "encourage" and "discuss" prevention strategies with people at risk, rather than simply providing a "lecture" on HIV prevention, it significantly reduces their risk of STDs.

In a study involving nearly 6,000 heterosexual men and women attending STD clinics in five U.S. cities, CDC found that talking with, rather than to men and women at risk actually resulted in a 20% decrease in new STDs among study participants overall, and a 40% decrease among adolescents and people diagnosed with an STD on their first visit.

Additionally, the study, published in the October issue of the Journal of the American Medical Association, found that the "encouragement" approach was just as effective in two brief twenty-minute counseling encounters as in a more extensive, four-session program. These findings indicate that, if well designed, brief interventions can make a significant impact.

"This study showed that it's not how much you talk to people about HIV prevention that matters most - but how you talk to them, especially if people are encouraged to participate in developing their own prevention plan," said Helene Gayle, Director of CDC's Center for HIV, STD, and TB Prevention, NCHSTP.

According to CDC, the brief sessions used in this study were not only as effective as the longer four-session intervention, but are feasible to implement in busy health care settings.

The CDC study, entitled Project RESPECT, compared brief (2 session) and enhanced (4 session) interactive prevention counseling to the brief (2 session) didactic (e.g. "lecture-type") messages typical of current care. The "encouragement" approach used in the interactive sessions was modeled after the personalized HIV counseling approach recommended by CDC since 1993.

Counseling was provided to HIV-negative heterosexuals at five public STD clinics in Baltimore, Denver, Long Beach, Newark, and San Francisco who came in for STD examinations. Participants were followed for twelve months to measure new STDs (gonorrhea, chlamydia, syphilis, and HIV) and self-reported condom use. The study is one of the few studies to date to measure not only condom use, but also disease outcomes.

Findings at each of the five sites showed a significantly lower incidence of STDs among both men and women participating in interactive counseling sessions, with the greatest impact among adolescents and individuals diagnosed with an STD at their initial visit.

"The program seems to make the greatest difference for those who need it most," said Dr. Kevin De Cock, Director of NCHSTP's Division of HIV Prevention - Surveillance and Epidemiology. "We know that the majority of new STD infections, including HIV occur among teens and young adults, and the interactive approach reduced risk among young people and others at high behavioral risk."

CDC believes that while the program was tested in STD clinics, the findings are likely to have relevance in any setting in which HIV and STD counseling is provided. Rather than simply providing the facts regarding how HIV transmission can be prevented, counselors in this program engage in a conversation with the individual at risk to identify a small behavior change the patient is willing to make. Counselors then build on this "first step" in the second session to develop a long range risk-reduction plan.

Lead CDC investigator on the study, Mary Kamb, M.D., M.P.H., explained how the conversation needs to differ from the current approach. "Instead of beginning with 'these are the facts about transmission and how to protect yourself', the counselors asks questions like - 'what's the one thing you think you could do next week to reduce your risk? How would you try bringing up using condoms with your partner?'"

In this study, the approach was implemented with existing clinic staff, in not much more time than that required for didactic messages, and cost only $8 additional dollars per client to implement. The costs were primarily related to training counselors and assuring the quality of counseling on an ongoing basis.

"Far too often, prevention programs found to be ideal in research settings are too difficult and expensive to implement in the real world," said Kamb, "With this program the ideal can be real, with few additional resources.'

As a result of these findings, CDC hopes that the approach will be widely adopted in STD clinics and other health care settings across the nation. CDC is refining its 1993 HIV Counseling and Testing recommendations to provide even more specific guidance on incorporating this now-proven approach to risk-reduction counseling. CDC will also provide technical assistance to facilities including training existing staff and monitoring the quality of counseling provided at clinics. According to CDC, clinics may have been reluctant to adopt this approach in the past because they didn't believe it worked better than didactic counseling or because they felt it was too costly and difficult to implement. This study should help put both fears to rest.

"When you compare an $8 investment in HIV prevention to the estimated $154,000 in lifetime treatment costs and the tremendous human suffering caused by HIV infection, there is no question that this investment is worth making," said Gayle.