A school-based HIV and STI risk-reduction intervention was effective in reducing sexual risk-taking behaviors among sixth-grade students in South Africa, according to a randomized controlled trial.¹ Pooled data from three follow-up assessments revealed that students who participated in the intervention were less likely than those who took part in a general health promotion program to have had unprotected vaginal intercourse in the past three months (2.2% vs. 4.2%). In addition, they were less likely to have had vaginal intercourse (4.8% vs. 7.2%) or multiple sex partners (1.8% vs. 3.2%) during that period. However, the proportion of students who had ever had sex did not differ between groups.

South Africa has approximately 5.5 million people living with HIV—more than any other country in the world. The incidence of infection is particularly high among those aged 15–24, underscoring the need for interventions aimed at young people. To assess one such program, investigators randomly selected and matched nine pairs of schools from Eastern Cape Province—seven pairs of urban schools from Mdantsane, the second largest South African township, and two pairs of rural schools from Berlin, a nearby settlement. One school in each pair was randomized to the risk-reduction intervention, while the other was assigned to the general health promotion program.

The intervention, which was rooted in various behavioral theories, and the general health program were each presented on six consecutive school days in two-hour sessions. Both included interactive exercises, games, brainstorming, role-playing and group discussions. The risk-reduction intervention focused on increasing students' knowledge of ways to reduce HIV and STI risks, their appreciation of the importance of using condoms and postponing sex, and their ability to use condoms and to talk with their partner about abstinence and condom use. The intervention sessions also addressed young wom-en's vulnerability to rape and other acts of male domination by discussing sexuality, sexual maturation, appropriate sex roles and rape myths. The health promotion program focused on behaviors associated with heart disease, hypertension, stroke, diabetes and cancer; its goal was to increase students' activity levels and their consumption of fruit and vegetables, and to reduce their use of cigarettes and alcohol.

A total of 1,057 sixth-graders (558 girls and 499 boys), with an average age of 12, participated in the trial. Most of the students lived in Mdantsane; 8% lived in Berlin. Fewer than half (39%) lived in a household with their father. In addition to completing a confidential questionnaire before the trial, students completed follow-up questionnaires three, six and 12 months afterward.

All participants attended the initial intervention session. Attendance at the next five sessions was nearly universal, ranging from 97% to 99%. Participation at each of the three follow-up evaluations was also very high (97%). Follow-up attendance was not related to gender, father's presence in the household, area of residence or sexual behavior.

At baseline, nearly all participants (97%) reported never having had vaginal intercourse. Young women were more likely than young men to report being sexually inexperienced (99% vs. 94%). While the proportion of sexually inexperienced students dropped to 77% by the 12-month follow-up, no difference was apparent between students in the intervention group and those in the control group. Moreover, no evidence emerged that the intervention postponed sexual initiation.

However, in generalized estimating equation analyses that averaged data from the three follow-up evaluations and controlled for baseline characteristics, students assigned to the risk-reduction intervention were less likely than those in the general health program to report having had unprotected vaginal intercourse (2.2% vs. 4.2%) or intercourse with multiple partners (1.8% vs. 3.2%) in the past three months (odds ratios, 0.5 for each). Additionally, the proportion of students who reported having had vaginal intercourse in the past three months was lower in the intervention group than in the control group (4.8% vs. 7.2%). The intervention's effectiveness did not change across the three follow-up periods. To validate the strength of findings from individual analyses, the researchers conducted meta-analyses of school-level intervention effects and found similar results.

The investigators noted that the relatively low rates of teenagers' sexual activity precluded use of STI or HIV incidence as outcome measures. Other limitations of the study, they said, include its reliance on self-reports of behavior and its unknown relevance to other South African adolescents. However, they pointed out strengths—the study's lack of self-selection bias (students did not know the content of the two interventions before enrollment), the use of a randomized design, and high rates of enrollment, intervention attendance and follow-up retention.

The researchers emphasize that the study is the first large-scale, community-level, randomized intervention trial to demonstrate significant effects on the sexual risk behaviors of young South African adolescents. "Sexual transmission of HIV is a major risk faced by adolescents in Sub-Saharan Africa, and interventions are needed urgently to reduce their risk," the investigators note. "Our results indicate that a theory-based, contextually appropriate HIV/ STD risk-reduction intervention delivered in schools can be effective in shaping the sexual behavior of young adolescents before or at the beginning of their sexual lives."—A. Kott

REFERENCE

1. Jemmott JB et al., School-based randomized controlled trial of an HIV/STD risk-reduction intervention for South African adolescents, Archives of Pediatric and Adolescent Medicine, 2010, 164(10):923–929.