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SAFE Studies Show Behavioral Intervention Reduces STIs in San Antonio, Texas

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.

Three Trials Taught Risk Recognition, Risk Reduction, and Communication, Then Measured Infections

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.

Results: Variety Is the Spice of Life

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.

Sexual Awareness for Everyone (SAFE) study at The University of Texas Health Science Center San Antonio
Current team (l to r): Andrea Longoria MA, Braulio Amezaga BA, Nicole Budrys MD, Rochelle Shain PhD, Sondra Perdue DrPH, Jennifer Newman PhD, Jessica Zesch MA, Olga Casias-Ahuyon. Drs Shain and Perdue have worked on Project SAFE since its inception.


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Last Updated November 12, 2010