For more than 20 years, NIAID has funded the Sexual Awareness for Everyone (SAFE) study at The University of Texas Health Science Center, San Antonio, targeting risky sexual behaviors in African- and Mexican-American communities that often lead to sexually transmitted infections (STIs). The behavioral intervention fine-tuned by the research team has been extremely effective at reducing STIs in these minority groups. In fact, SAFE is recognized by the Centers for Disease Control and Prevention as a best evidence program to reduce chlamydia and gonorrhea infections and risky sex behaviors.
SAFE researchers have conducted three randomized trials using a unique behavioral intervention to reduce the prevalence of chlamydia and gonorrhea. But before the trials began, researchers spent 18 months collecting qualitative information from the target groups to better understand the needs, beliefs, and practices that would have to be addressed in the intervention as well as cultural strengths that could be used to motivate change.
“We believed that STIs could be prevented through a culture- and gender-specific behavioral-cognitive intervention,” explained anthropologist Rochelle Shain, Ph.D., who led the study. The intervention had three goals: 1) to make individuals aware that their (and their partners’) behaviors can place them at high risk of contracting STIs, 2) to increase their motivation to change risky behavior, and 3) to provide them with the skills and support to do so. This reasoning was based on an adaptation of the AIDS Risk Reduction model.
In SAFE 1, the first of the three trials, 617 female study volunteers were randomized to control and intervention groups. The latter participated in three weekly interactive sessions that focused on risk recognition, commitment to reduce risk and communication skill-building. Each small group was matched by a facilitator of the same ethnicity. The sessions aimed to: empower individuals and cultivate self-confidence, raise their consciousness with regard to relationship needs with male partners, dispel myths associated with STI transmission, negotiate condom use, and educate about consequences of STIs.
At one-year follow-up, the researchers reported a 38 percent reduction of gonorrhea and/or chlamydia among women assigned to intervention. The intervention worked equally well for African- and Mexican-Americans, the depressed and non-depressed, and adolescents and adults. Behaviors responsible for this reduction included reducing number of partners and rate of partner turnover, practicing mutual monogamy, not having sex with a man before he was fully treated for STIs, avoiding unsafe sex, and not douching after sex.
Subsequent studies tested the addition of support groups (SAFE 2) and the inclusion of male partners (SAFE 3). In SAFE 2, women were assigned to intervention with and without the option of monthly support groups; one year later, both groups of women were more than 40 percent less likely to have chlamydia and/or gonorrhea. After 5 years, these trends persisted. A third trial, SAFE 3, included male partners and produced even greater STI reductions for women and men.
Dr. Shain attributes the success of SAFE to its multifaceted approach. “Individuals can choose different paths to avoid STIs,” she explains. “SAFE is not limited to encouraging condom use, but includes a mix of options.” These options include practicing abstinence or limited periods of abstinence, engaging in mutual monogamy, reducing number of partners and concurrency, not settling for an unsatisfactory relationship, taking time between partners to be selective, using condoms consistently and correctly, learning how to eroticize condom use, not douching after sex, and increasing health-seeking behavior.
Since STI infection is associated with poverty, low educational levels, and low self-esteem, SAFE stresses empowerment and treats the whole person. For example, program materials include a detailed self-help booklet to help participants obtain a GED, find employment, seek housing assistance. and more. Participants are put in touch with their community's cultural strengths, such as love of family and avoidance of infertility.
In addition to SAFE’s unique approach, the research team was central to the program’s success. "These studies could not have been successfully conducted without a strong team effort (co-principal investigators, co-investigators, and clinic staff) and collaboration with Dr. Fernando Guerra, director of the San Antonio Metropolitan Health District. We give special thanks to Dr. Joel Baseman and NIAID who provided this opportunity," says Dr. Shain.
Catania JA, Kegeles SM, Coates TJ. Towards an understanding of risk behavior: An AIDS Risk Reduction Model. Health Education Quarterly. 17(1):53-72 (1990).
Shain RN, Piper JM, Newton ER, Perdue ST, Ramos R, Champion JD, Guerra FA. A randomized, controlled trial of a behavioral intervention to prevent sexually transmitted disease among minority women. New Engl J Med. 340(2):93-100 (1999).
Ramos R, Shain RN, Johnson L. "Men I mess with don't have anything to do with AIDS": using ethno-theory to understand sexual risk perception. Sociol Q 36:483-504 (1995).
Korte, JE, Shain RN, Holden AE, Piper JM, Perdue ST, Champion JD, Sterneckert K. Reduction in sexual risk behaviors and infection rates among African Americans and Mexican Americans. Sexually Transmitted Diseases. 31(3):166-73 (2004).
Holden AE, Shain RN, Miller WB, Piper JM, Perdue ST, Thurman AR, Korte JE. The influence of depression on sexual risk reduction and STD infection in a controlled, randomized intervention trial. Sexually Transmitted Diseases. 35(10):898-904(2008).
Thurman AR, Holden AE, Shain R, Perdue S, and Piper J. Partner notification of sexually transmitted infections among pregnant women. Intl J of STD & AIDS. 19(5):309-15 (2008).
Shain RN, Perdue ST, Piper JM, Holden AE, Champion JD, Newton ER, Korte JE. Behaviors changed by intervention are associated with reduced STD recurrence: the importance of context in measurement. Sexually Transmitted Diseases. 29(9):520-9 (2002).
Shain RN, Piper JM, Holden AE, Champion JD, Perdue ST, Korte JE, Guerra FA. Prevention of gonorrhea and Chlamydia through behavioral intervention: results of a two-year controlled randomized trial in minority women. Sexually Transmitted Diseases. 31(7):401-8 (2004).
Thurman AR, Holden AE, Shain RN, Perdue S, Piper JM. Preventing recurrent sexually transmitted diseases in minority adolescents: a randomized controlled trial. Obstetrics & Gynecology. 111(6):1417-25(2008).
Last Updated November 12, 2010