Evaluation of Interventions to Decrease the HIV/STI Risk Behaviors of African American
Youth: Can We Control Future Trends?
Beatrice Simiyu
Capstone Project
Dr. Bruce Johnson Abstract
As a result of the need to recognize successful human immunodeficiency virus (HIV) and sexually transmitted infections (STI) interventions tailored for African American youth, a literature review of six HIV/STI randomized controlled trials interventions targeting African American youth conducted in the United States were evaluated. A comparative analysis was used; the settings, procedures and outcomes of the different interventions targeting African American youth were compared, contrasted and combined to ultimately identify trends that are likely to initiate and possibly sustain change in HIV/STI risk behaviors among African American youth who are a vulnerable group. Variables were evaluated by the various intervention impacts on reducing sexual risk behaviors by an indication of a delay in first sexual intercourse, a decline in the number of sex partners and frequency of sex, and increase in condom use and a reduction in positive STI outcomes. Outcomes were used to facilitate identification of public health strategies that might be most beneficial in targeting African American youth and pinpoint what manner current public health strategies neglects to focus on their needs.
The research and practice implications of the findings imply that enhancing future HIV/STI targeting African American youth necessitates the prioritization, development and evaluation of “innovative, theory based, empirically derived, and rigorously designed research specially tailored to the cultural, gender, and socio demographic characteristics of the target population” (Sales, Milhausen &Diclemente, 2006, p. 435). Recommendations include addressing HIV/STI social and behavioral risk factors to change African American youth social and behavior norms by involving schools and community based organizations in innovative ways.
Keywords: HIV/AIDS, STI, African American, youth, disparities, interventions, prevention Introduction
Sexually transmitted diseases (STIs) including human immunodeficiency virus (HIV) present a critical and prevalent health risk in the United States. Despite the fact that most STIs are can be easily detected and treated, a considerable number have no obvious symptoms some infected individuals might not seek testing or therapy. Consequently, numerous infections can go undetected for extended periods of time. Without treatment, individuals with STIs are at risk of serious health problems, including infertility. Individuals with an STI are “at least two to five times more likely to become infected with HIV, if exposed to a partner who has HIV, than people who do not have an STI” (Centers for Disease Control and Prevention (CDC), 2012, p. 1).
HIV/STIs occur in individuals of all races, ethnicities and ages; however, some populations encounter more challenges in safeguarding their health. Surveillance data implies that African Americans are disproportionately affected by HIV /STIs take, especially the younger population. Blacks denote merely 14% of the U.S. population, but account for one-third of all reported chlamydia cases, almost half of all syphilis cases, and two-thirds of all reported gonorrhea cases (CDC, 2012). Although there has been significant progress in the prevention and control of HIV/STIs, it has been established across studies that African Americans are at greater risk of infection than communities (Fasula & Miller, 2006). CDC (2009) implies that in comparison with the total U.S. adolescent population, African American adolescents are at a higher risk for undesirable health, academic, and social outcomes due to effects of risky sexual behaviors. Risky sexual behaviors, increase the risk for HIV and STI infection, and have also been linked with poorer degrees of academic achievement, intensified high school drop-out rates, and poor social outcomes (Romero et al., 2011).
Individual risk behaviors, peer influence, cultural and family dynamics accompanied by barriers to knowledge and prevention services enhance the risk of infection. Almost 70% of all high school youth experience their sexual debut by age 18. The average reported age of sexual debut for youth in the United States is 14.4 years, with approximately 7% reporting their sexual debut prior to age 13 (CDC, 2010; Romero, Galbraith, Wilson-Williams & Gloppen 2011). African-American youth tend to experience their sexual debut earlier than other racial/ethnic groups (Miller et al., 2009). An early introduction to sex presents considerable health risks, including participating in unprotected intercourse, thus, an increased risk of contracting STIs and HIV. An individual’s social setting can influence the accessibility of healthy sexual partners.
Due to the fact that untreated STIs and HIV are already more prevalent in the African American population than in others and because African Americans are prone to select sexual partners within their own groups, they confront a greater likelihood of infection with each sexual encounter. As a matter of fact, research indicates an African American with one sex partner has greater risk of acquiring an STI compared to a white individual with multiple sex partners (Adimora & Schoenbach, 2005). The socio-economic status affects sexual behavior in that those who strain financially may be in situations that increase their risk for HIV/STIs. Lack of health insurance limits access to STI testing and other prevention services (Hogben & Leichliter, 2008).
Distrust in the medical system reduces the likelihood of an African American to seek medical attention supporting the fact that African Americans are less inclined to utilize medical services in comparison to whites (Forhan et al., 2009). This encourages the transmission of HIV/STIs due to lack of detection and treatment. The lack of cultural competence among practitioners may also play a major role in breaching communication with African Americans, increasing the level of uncertainty about the healthcare system.
Schools have been the ideal setting to change behavior since they have access to majority of the adolescents, unfortunately, the current high school youth risk behavior survey conveys that nationwide, 84.0% of students reported that they had ever been taught about AIDS or HIV infection in school, furthermore, the prevalence of having ever been taught in school about AIDS or HIV infection also decreased from 2009 (87.0%) to 2011 (84.0%) (Eaton et al., 2012). The consequences are apparent and African Americans are impacted the most; In 2007, for example, the gonorrhea rates among African American adolescent females 15–19 years was 14.7 times greater than their white counterparts and the rate for adolescent African American males 15–19 was 38.7 times higher than for Caucasian males (Whitely et al., 2012). The statistics imply that that there has to be a better approach that addresses sexual behavior in African American youth since the schools have not been successful.
The many social and cultural risk factors that surround African Americans necessitate that interventions seeking to change sexual behavior to reduce the incidence and prevalence of HIV/STI in the group to be tailored to uniquely address the protective factors including self-efficacy, perception of positive peer group attitudes, and parental communication. To ensure that risky sexual behavior is modified, it is important to address both the individual, social and environmental factors that contribute to HIV/STI risk. The purpose of this paper is to evaluate HIV/STI interventions targeted for African American youth since HIV/STI risk behaviors usually originate in youth. Behaviors established during adolescence are more likely to be sustained through adulthood. Intensifying prevention efforts among the youth provides an opportunity to reduce and sustain the impact of HIV/ STI on the next generation of African American adults (Miller et al., 2009). Variables were evaluated by the various behavior and theory based intervention impacts on reducing sexual risk behaviors by an indication of abstinence, a delay in first sexual intercourse, a decline in the number of sex partners and frequency of sex, increase in correct and consistent condom use and a reduction in positive STI outcomes. Outcomes were used to facilitate identification of public health strategies that might be most beneficial in targeting African American youth and pinpoint what manner current public health strategies neglects to focus on their needs. Recommendations for future African American HIV/STI interventions are provided.
Background
African Americans remain one of the groups most disproportionately affected by HIV/STI in the United States (Kaiser Family Foundation (KFF), 2013). This emphasizes the need to influence the African American youth with effective HIV/STI prevention interventions at a time when sexual behavior is being established. HIV and STIs are preventable but their prevalence and incidence is higher in the African American community (DiClemente et al., 2009; Romero, Galbraith, Wilson-Williams & Gloppen (2011). The CDC (2010) conveys that African Americans account for a higher proportion of HIV at all stages of disease from new infections to deaths. They represent approximately 14 percent of the U.S. population, and account for almost half of the more than one million people estimated to be living with HIV in the United States, and nearly half of new HIV infections annually.
Furthermore, of the nearly 25,000 infections estimated to occur each year among African Americans, more than 38 percent are among young people aged 13 to 29 (CDC, 2010). An assessment of national household survey data indicated that 2% of Blacks in the U.S. were HIV positive, and is greater higher than any other group (KFF, 2013). The AIDS diagnosis rate per 100,000 among African American adults and adolescents was 9 times that of whites in 2009. The rate of new HIV infections is also highest among blacks and was nearly 8 times greater than the rate among whites in 2009. Romero et al. (2011) cite that in 2007, the 34 states with long-term confidential name-based HIV reporting, reported that 72% of HIV/AIDS diagnoses among 13–19-year-olds were among African Americans, yet African Americans accounted for only 17% of the general population in this same age range.
The High School Youth Risk Behavior High School Survey (YRBS) reports that 67.6% of African American students (74.6% of males, 61.2% of females) reported having participated in sexual intercourse at least one time; besides, many begin sexual intercourse as preadolescents (Miller et al., 2009). The current YRBS indicators evaluated by Eaton et al. (2012) convey that nationwide, the prevalence of being currently sexually active was higher among blacks at 41.3%, (46.0% male, and 36.9% female). The prevalence of having had sexual intercourse before age 13 years was also higher among blacks (13.9%) with 21.2% of males and 7.0% of females. Participation in sex with multiple partners places youth at added risk for HIV and STIs. The prevalence of having had sexual intercourse with four or more persons was higher among blacks (24.8%) with 32.6% male and 17.5% female. The 2009 statistics indicate that 38% did not use a condom during a recent intercourse encounter (CDC, 2009). A CDC study estimated that in the United States, almost one in two (48%) African American girls aged 14–19 is infected with at least one of the common sexually transmitted diseases including chlamydia, human papillomavirus, herpes simplex virus, or trichomoniasis (Forhan et al.,2009). Risky sexual behaviors heighten the risk for HIV /STI infections and poor social outcomes (Romero et al., 2011).
The impact of HIV/STI on African American youth is disturbing. The burden of HIV/STI among African Americans is due to both individual-level behaviors and social context influences that enhance the spread and may be especially significant in African American communities, which are prone to be socially isolated, depicted by higher rates of poverty and joblessness (Adimora & Schoenbach, 2005). These socioeconomic disparities interact and increase the likelihood of high risk behaviors and intersect between individuals in low and higher risk sexual networks (Adimora et al., 2006; Hogben & Leichliter, 2008). Effective behavioral interventions proven to decrease HIV/STI risk behaviors focus on specific behaviors relevant to the target population, include clear messages about situations leading to risk behaviors, and describe methods to prevent these situations (DiClemente et al., 2009; Guilamo-Ramos et al., 2011; Miller et al., 2009; Stanton et al., 2004; Sznitman et al., 2011a, b; Turner-Musa, Rhodes, Harper, & Quinton, 2008).
Due to the fact that HIV/STI risk behaviors usually originate in youth, intensifying prevention efforts with youth provides an opportunity to reduce and sustain the impact of HIV/ STI on the next generation of African American adults. In countries where HIV prevalence has declined at population level, sexual behavior change among young people has been cited as an important contributing factor (Ross, Dick & Ferguson, 2006). With African American youth aged 15 to 19 encountering higher HIV/STI prevalence in the United States (Eaton et al, 2012); the development of effective HIV/STI prevention interventions targeting them should be regarded as a top public health priority. In reaction to the individual and public health threat posed by the disproportionate rates and staggering effects of HIV/STI among African American youth, over the past decade a number of sexual risk-reduction interventions tailored for the demographic have been conducted and published in peer-review medical, public health, and social science journals in the United States.
The Centers for Disease Control and Prevention have instigated an enhanced national response to address this predicament by developing prevention interventions targeted for African Americans youth (Miller et al, 2009). Various behavioral interventions have been developed to educate African American youth at risk of infection about risky sexual behavior and to teach them the personal skills needed to avoid unsafe sex including, negotiation skills that help them persuade their partner to use a condom (Borawski et al., 2009, Jemmott III, Jemmott, Braverman, & Fong, 2005; Jemmott, Jemmott, Fong. & Morales, 2010; Sznitman et al., 2011a). The research procedures from successful HIV behavioral interventions have been replicated for use by HIV/STI prevention providers, including health departments, schools, and community based organizations (Jemmott III et al., 2010; Stanton et al, 2004; Sznitman et al., 2011b; Walcott, Meyers, & Landau, 2008). Most of the interventions developed specifically for use with African American youth to prevent HIV/STI infection have been effective, based on the outcomes of meticulously designed trials (Baranski et al., 2009). The expansion and delivery of several, evidence-based, culturally relevant behavioral HIV/STI prevention interventions has been a significant progress in combating the HIV/STI epidemic among African American youth, however there remains room for additional improvements. To improve their effect on the prevalence of HIV/STI, it is possible to modify and supplement evidence based interventions addressing HIV/STI prevention, to increase and sustain the outcomes.
The review indicates that uncertainties linger concerning how to attain and sustain the individual level behavioral modifications needed to reduce HIV/STI incidence in the group. In spite of recent calls to increase attention to the high levels of HIV/STI transmission to African American youth, there is a gap in that inadequate methodical unanimity exists on how to effectively to prevent HIV/STI infection among the youth in the demographic. Although the interventions reduce the incidence of STIs, they usually involve several sessions of individual or group counseling and are possibly too complex to implement. There is a need to design simpler interventions that are not time consuming. Since methodical reviews are in published analyses, up-to-date studies may be absent albeit these may present significant lessons learned, facilitating the recognition of favorable approaches. Pedlow and Carey (2003) suggest that the impact of an intervention may diminish with time after intervention delivery. Follow up periods in the reviewed studies were up to a maximum of 24 months with only one having a 24 month follow-up (Stanton et al., 2004). It is possible that had the participants been followed-up for longer significant differences in outcomes like condom use may have been higher. To enhance their impact on the issue, the follow up periods need to be longer to enable sustainability of outcomes and also gauge their potential to sustain change. Besides, although some STI’s were tested as a biological outcome, none of the reviewed studies reported testing for HIV as a biological outcome. ‘‘Given the limited resources available for prevention and change programs, it is essential that interventions focus upon changing those constructs that have the greatest probability of influencing the likelihood that members of a given population will engage in the behavior in question’’ (as cited in Romero et al., p. 977). Nevertheless, evidence pertaining to effectiveness of most interventions is still developing. This capstone project relates to the gaps in the implementation of interventions targeting African American youth in that it will focus on the elements that have proven effective in changing the attitudes and perceived outcomes associated with the diseases. Evaluating the aspects of carefully designed African American youth interventions will lead to a better understanding of how they work and why they are successful. In addition, reinforcing and widening prevailing approaches, programs, and adopting new approaches to reduce youth HIV incidence among African American youth are equally important.
The studies reviewed suggest that the interventions had an impact on HIV/STI knowledge and attitudes, self-efficacy, and also self-reported biological outcomes. Sexual decision making is a complex behavior and is influenced by many factors; thus developing proficiencies in other, related areas can reinforce African American youth sexual decision making skills (Robin, et al., 2004). Lessons learned from these reviews include the need to change African American youth norms regarding sexual risk behaviors, and to address a broad range of interpersonal, cultural and structural factors influencing HIV/STI risk behavior. Interventions that were most effective targeted behaviors that are most responsive to change, like condom use; tailored programs for a specific target population, for instance, females (DiClemente et al., 2004; DiClemente et al., 2009; Jemmott III et al., 2005); utilized theory to guide intervention development; and addressed more than just one sexual risk factor (Stanton et al., 2004). Interventions focusing on multiple factors for instance, promoting abstinence amongst preadolescents while emphasizing condom use, skill in condom use and self-efficacy in using condoms, beliefs about negative consequences of condoms for sexual enjoyment, and skill and self-efficacy in negotiating condom use, peer pressure or personal pride prove to be effective in decreasing early sexual debut and improving self-efficacy hence controlling the prevalence of HIV/STI. However, there is controversy surrounding appropriateness of implementing early sexual risk prevention programs for younger adolescents (Miller et al., 2009; Morrison-Beedy, Carey, Côté-Arsenault, Seibold-Simpson, & Robinson, 2008; Pedlow & Carey, 2004; Stanton et al., 2004). Throughout the various articles reviewed, interventions delivered in different settings, indicate that the risk behavior most predisposed to change was condom use during sex (Borawski et al., 2009; Jemmott III et al, 2005; Jemmott III et al., 2010; Sznitman et al., 2011a). Parents also played a major part in influencing the behaviors of the youth as supported by previous reviews (Fasula & Miller, 2006; Guilamo-Ramos et al., 2011; Miller et al., 2009; Stanton et al., 2004). Some STI/HIV prevention programs showed favorable effects in increasing abstinence or reducing the number of sexual partners (Sales et al., 2012; Stanton et al., 2004). Interventions that included comprehensive content, like problem solving, decision-making skills, capacity building, social skills building, and enhancing gender and ethnic pride, had the greatest impact on reducing STI/HIV sexual behaviors (DiClemente et al., 2004).
Future interventions with adolescents, especially adolescents who are sexually active, should target behaviors, like condom use, that have been demonstrated across a variety of adolescent subgroups and venues to be most responsive to change. Utilizing a focused approach that targets only those areas of behavioral change that are reasonable and feasible for African American adolescents to accomplish may result in prevention efforts that not only reduce the adolescents' sexual risk behaviors, but lay the foundation for more sustainable sexual risk-reduction over time. Ultimately, a comprehensive approach may result in reductions in HIV/STI among African American youth.
Methods
Due to the higher prevalence and incidence of HIV/STI in the African American population (Miller et al., 2009), this capstone project evaluates the effects of HIV/STI interventions on sexual risk behaviors, STI rates and mediating factors such as knowledge and attitudes that affect those behaviors among African American youth. Evaluation is a hypothetical approach to the use of data as a component of the public health improvement process; therefore data on the common characteristics of six interventions that were effective in changing sexual risk behaviors among African American youth in the United States between 2003 and 2012 are evaluated. The project addresses the characteristics of interventions that have been effective in decreasing the prevalence and incidence of HIV/STI to guide future interventions and modify trends in the future generations.
The current youth risk behavior surveillance data on the African American youth risky behavior and epidemiological data regarding the scope of HIV/STI in the African American population will be included to establish the need for addressing the problem (Eaton et al., 2012; CDC, 2010). Among other variables, the data includes the type of intervention, conditions under which the interventions were developed and implemented, the intervention delivery, the intensity and duration of the curriculum, the follow up period, the setting, and the subgroup in terms of male, female, sexually experienced or inexperienced. Based on the data analysis, the strengths and limitations of the various interventions will be applied to project intervention variations that would work the best for the African American youth to change current prevalence and incidence trends.
Identification and description of the data that will be analyzed
Data collected includes intervention content involving peer discussion, one-on-one interaction, parents, and school, community or media awareness activities among African American youth 11 to 19 years of either gender in any setting. The research methods with a clear and detailed description of the intervention development, content, and implementation are invaluable facts. The study design with both intervention and comparison groups and both pretest and posttest data collection will also be part of the data analyzed. The number of participants in an intervention is considered in addition to the various follow up periods to enable analysis of the significance of the intervention effect or outcome. The intervention impact upon one or more of the following sexual behaviors: initiation of sex, frequency of sex, or number of sexual partners; use of condoms and combined measures of sexual risk for instance frequency of unprotected sex and HIV/STI infection is collected and compared against the various interventions. The impact on those behaviors that can change quickly (for at least 3 months) including frequency of sex, number of sexual partners, use of condoms, or sexual risk-taking, and the impact on those behaviors or outcomes that change less quickly (for at least 6 months) for instance initiation of sex, or STI rates, will be recorded. Qualitative evaluation of the data will focus on intervention effectiveness based on:
• What was done or occurred
• With what intensity
• For what duration
• How
• Where
• When
• To whom
• With what variations for all the above
Description on the methods of data analysis
Comparative analysis will be used to analyze the data from the 6 main interventions identified. Data from the studies will be compared and contrasted to the point where no new concerns will be arising. All identified studies meeting these criteria will be reviewed and specific information from each study summarized on a spreadsheet. Key data such as characteristics of the sample, the characteristics of the intervention, research methods, and effects on both sexual risk behaviors and mediating factors like applicable knowledge and attitudes are compared. All effects on behaviors or mediating factors were considered significant if they were statistically significant at the p < .05 level and based on the total study population in the sexually experienced or inexperienced youth. Since very short term effects on behaviors would have had little impact on HIV/STI prevalence, only those results for 3 months or 6 months (depending on the behavior) or longer will be considered significant.
A criterion will be established to assess the consistency of each study based on the several sources. Initially, criteria for assessing procedural strengths were adapted from a previous review article reviewing sexual risk reduction interventions for African American adolescents. There are a few evaluation criteria from the sources including a distinct description of study location and sample, design of hypothetical context, clarification of study implementation, an explanation of the intervention content and behavior change methods adequately described to allow replication. An account of the content for the control group, indication of length of follow up, indication of retention rates reported for each study condition; and sample size justification will also be considered. These criteria are regarded as essential to properly designed and implemented studies. Special codes would be assigned to the different interventions and concerns the studies are reviewed, noting the relevant section when any of the interventions or concerns appear. As each new topic is mentioned, another code would be assigned and the studies would be reviewed to ensure that no variables are missed during the initial evaluation. By end of the process, it would be a comprehensive analysis.
Distinguishing features of effective programs
After analyzing the reported behavioral and/or biological outcomes of the interventions evaluated, the common characteristics of those interventions that were effective at changing behavior will be determined by creating a comprehensive list of potentially important characteristics of programs from the reviews. The common characteristics of intervention development and implementation, among the studies identified, and had the strongest evidence for positive behavioral effects were also listed. To accurately determine the characteristics of the process for developing and implementing the effective interventions, the descriptions of how the interventions were developed and implemented will be coded and reviewed. These descriptions became the basis for the characteristics describing the development and implementation of the interventions.
The activities in theses interventions were coded based on the risk and protective factors they addressed. Activities from the interventions addressing the same risk and protective factors were grouped and reviewed. The goal of the comparative analysis is to present a meaningful conclusion about the characteristics being compared; the characteristics that were incorporated into the interventions become the common characteristics of effective interventions that can be utilized in impending interventions focusing on African Americans youth to make a difference.
Data Analysis
As a result of the need to recognize successful HIV/STI interventions, relevant data is used to evaluate the evidence base for African American youth HIV/STI prevention. The data analysis focuses on study design and outcomes, intervention design, content and adaptation procedures, intervention delivery in terms of duration, potency, who, means, and setting. The HIV/STI prevention interventions reviewed were all comparable in HIV/STI prevention subject matter and intentions, but differed in thematic focus, theorized contributing aspects, delivery method, intensity and duration.
Data from the 6 main intervention studies that met the relevant criteria (BOX 1) were utilized to summarize a description of each intervention. Interventions which taught skills that could facilitate infection and the transmission of HIV/STI among the youth in addition to the provision of facts and information about HIV and STIs and those that involved parents would be most likely to address prevailing needs (Fasula, & Miller, 2006, Guilamo-Ramos et al., 2011, Sznitman et al., 2011a,b, Stanton et al., 2004). Significant information from each study was condensed on a table and spreadsheets (Table 1, 2 and 3), laying emphasis on the principal focus of the study and proposed approaches to accomplishing the interventions’ main outcomes. The most important analytical categories were designated an inference, based on characteristics of interventions demonstrated to be successful for the demographic in various settings (Crepaz et al., 2009, DiClemente, et al., 2004, 2009, Guilamo-Ramos et al., 2011, Jemmott III, et al., 2005; Jemmott III et al., 2010; Pedlow, & Carey, 2004), even though when activities are excluded or the setting is changed, they are less likely to have a significant optimistic effect (Borawski et al., 2009). These categories comprised of: Study design, setting, selected participants, demographics, number of participants, intervention content and process, ( how and where the intervention was delivered for instance community settings, and who delivered the intervention ) follow up and retention, (comparing with incentives against those without),measured outcomes (clinical and behavioral), statistical significance and conclusions.
A summary of what the interventions were based on and the aspects of behavior change that were influenced were tabulated on a summary of intervention content and effects on behavioral and non-behavioral outcomes table (Table 2, 3). The content includes: cultural adaptation; use of theory; focus on social context and risk environments, as well as individual risk behaviors; and focus on HIV/STI knowledge; utilization of social/behavioral theory constructs; incorporation of cultural constructs; inclusion of STI testing; involvement of parents; engagement of participants trough role playing, exercise and games; include measures of mediators/social/ structural factors; used peer groups and supplied condoms.
Self-efficacy, knowledge attitudes, beliefs, intentions and biological outcomes were categories used to analyze data pertaining to outcomes in order to gauge the degree of intervention effectiveness (Table 3). The intervention impact upon one or more of the following sexual behaviors: initiation of sex, frequency of sex, or number of sexual partners; use of condoms and combined measures of sexual risk for instance frequency of unprotected sex and STI infection is collected and compared against the various interventions to come up with results and conclusions.
Analysis of study results
All identified studies meeting the relevant criteria were reviewed and significant information from each study was condensed on a spreadsheet that included essential data such as characteristics of the sample, the characteristics of the intervention, research methods, and effects on both sexual risk behaviors and enabling factors like applicable knowledge and attitudes. The outcomes on behaviors, knowledge and attitudes were regarded significant they were statistically significant at the p < .05 level.
Some interventions conveyed results for multiple measures of each behavior, for different periods of time, for different subgroups, or for different combinations of the above. The impact on those behaviors that can change quickly was coded example, frequency of sex, number of sexual partners, use of condoms, or sexual risk-taking) for at least 3 months, and the impact on those behaviors or outcomes that change less quickly (for instance initiation of sex, or STI rates) for at least 6 months was coded. Some studies reported one or a very small number of positive effects on behavior but also reported some insignificant results. To prevent the presentation of merely the positive results and to deliver a more balanced overview, the following guidelines for analyzing the intervention outcomes were implemented.
• With regard to diverse measures of the same outcome, all measures across all studies were sorted based on their likelihood to influence the on prevalence of HIV/STI. For instance the use of condoms over 12 months was ranked higher the use of condom at initial sex. Only the results from the highest ranked measure reported in each study were included in tables.
• With regard to duration, due to the fact that shorter term effects on behaviors would most likely have an insignificant effect on HIV/STI prevalence, only those results for 3 or 6 months or longer were included in tables.
• Pertaining to participants, the results had to depict at least one third of the intervention participants or more.
Identification of characteristics of effective interventions After analyzing the behavioral and biological outcomes of the evaluated interventions, a three-step process was used to determine the mutual characteristics of those programs that were effective at making a difference in behavior and attitudes. This methodical charting gave a summary of the existing data and allowed the evidence to be grouped according to combinations of the characteristics used to code the articles. The studies were grouped according to the various different characteristics to enable the establishment of trends (Table 1).
Step I
To establish a comprehensive list of hypothetically important characteristics of interventions, reviews of health education and HIV/STI education programs for African American youth or adolescents, and sex and HIV/STI intervention for young adults were done (Miller, et al., 2009; Morrison-Beedy et al., 2008; Romero et al., 2011; Walcott, Meyers, & Landau, 2008). Some studies that were not effective also reviewed to compare and contrast the implementation strategies during discussion (Borawski et al., 2009; Turner-Musa et al., 2008). Table 1 is the summary of proposed characteristics of effective HIV/STI youth interventions based on the review of the relevant studies.
Step II
To recognize the shared characteristics of intervention content among the 6 studies, several interventions that had the strongest evidence for positive behavioral outcomes were reviewed. Most activities in these interventions were coded based on the risk and protective factors they addressed. Activities from various interventions addressing the same risk and protective factors were reviewed. The intervention programs were rated on each of the potentially important characteristics that was either on the list of hypothetically important characteristics identified in the first step or that arose from the detailed review. The characteristics that were integrated into the most number of effective interventions made up the common characteristics of effective intervention content (Table 1).
Step III
In order to accurately select the characteristics of the process for developing and implementing the effective programs the descriptions of how the interventions were developed and implemented was reviewed, coded and tabulated on the spreadsheet creating the foundation for the development and implementation of effective interventions intended for African American youth. Even though the intervention studies were coded impartially, the end result includes some level of reasoning to a certain extent, since some studies did not have a distinct and thorough account of the intervention program development, subject matter, and implementation.

Box 1

Intervention inclusion criteria

• Participants: vulnerable African American youth aged 11–19 years.
• Interventions: behavioral and social interventions that target prevention of HIV/STIs infection among African American youth.
• Comparison requirement: any comparator allowed.
• Outcomes: changes in sexual behavior and intentions including abstinence from sexual activity, condom use, number of sexual partners.
• Study Design: outcome evaluations (RCTs)

Systematic review inclusion criteria.

• Participants: young people aged 11–19 years.
• Intervention: behavioral interventions based in (but not restricted to) schools in which an element of the intervention included the development of sexual behavioral skills (e.g. how to use a condom; how to negotiate safer sex with partners). Studies evaluating interventions teaching skills outside the context of sexual health (e.g. life skills).
• Comparison requirement: any comparator allowed.
• Outcomes: self-reported sexual behavior e.g. abstinence, condom use, number of sexual partners, biological testing.
• Study Design: RCTs only.

Table 1: Characteristics of effective HIV/STI youth interventions
Intervention Program development Contents of the intervention Implementation of the intervention
Assessed appropriate needs of target population

Used a relevant approach to develop the program by specifying the goals, the behaviors influencing the health goals and the protective factors affecting those behaviors and the activities addressing the risk and protective factors

Designed activities that were age appropriate, consistent with community values

Pilot tested the intervention Goals and objectives
Concentrated on well-defined health objectives for the prevention of HIV/STI

Concentrated on specific behaviors that lead to the objectives for instance abstinence and condom use, gave clear messages about these behaviors and tackled circumstances that cause them and how to avert them.

Tackled multiple psychosocial risk and protective factors affecting sexual behaviors for instance knowledge, perceived risks, attitudes, perceived norms and self-efficacy

Activities and methods
Set up a safe environment for the youth to get involved

Included multiple activities to change the targeted risk and protective factors

Utilized activities, methods and behavior messages that involved the participants, were appropriated to the participants’ culture, age and sexual experience. Gained support from parents, health organizations and community based organizations

Implemented activities to recruit and retain youth and overcome barriers to participation. For instance involving parents or using healthcare providers.

Selected mentors with desired characteristics or trained them; observed and oversaw their activities

Results
The emphasis of this project is to evaluate successful HIV/STI interventions targeting African American youth to determine the common single or multi-level approaches utilized and in turn provide recommendations for future interventions to decrease the prevalence and incidence trends of HIV/STI among African Americans. Qualitative data analysis of literature review and content comparative analysis of studies and intervention measures performed in different settings gauged intervention measures designed at addressing and preventing HIV/STI risk behaviors by addressing the behavioral, social and cognitive risk factors that affect African American youth. The results are broken up into: Impact of programs on sexual risk behaviors and HIV/STI rates, impact of programs on mediating factors for sexual risk behaviors, and mutual characteristics of effective STI/HIV youth interventions (Table 1).The six African American youth intervention studies implemented to prevent HIV/STI high risk behaviors that met the inclusion criteria had numerous characteristics in common; many of them incorporated many of the characteristics of programs previously found to be associated with effectiveness (Albarracín et al., 2005; Pedlow & Carey, 2003; Romero, Galbraith, Wilson-Williams, & Gloppen, 2011; Robin et al., 2004; Sales, Milhausen, & DiClemente, 2006; Sznitman et al., 2011a, b).
Effect of interventions on sexual risk behaviors HIV/STI outcomes
The data analyses from this review enlighten what works to prevent STI/HIV infections among African American youth. The review recognizes the elements related with intervention impact, and draw attention to favorable approaches in preventing HIV/STI among African American youth. The six interventions signify advancement toward improved HIV/STI prevention, based on behavioral and biological outcome measures for HIV/STI infection. Initially conducting formative research and pilot studies to inform development of the intervention for culture and developmental appropriateness proved critical for the success of the interventions (Jemmott III, Jemmott, Braverman, & Fong, 2005; Jemmott III, Jemmott, Fong, & Morales, 2010; Diclemente et al., 2004; Diclemente et al., 2009; Stanton et al., 2004). The studies also increased effectiveness by employing culture or gender specific intervention themes; utilization of social/behavioral theory constructs (Guilamo-Ramos et al., 2011; Jemmott III et al., 2010; Stanton et al., 2004); used facilitators that had experience working with African American youth in different settings (Jemmott III et al., 2005; Jemmott III et al., 2010), involved parents(Guilamo-Ramos et al., 2011; Stanton et al., 2004); empowered the youth by addressing self-efficacy for protective behavior, confidence, and equality in relationships; provided condoms, skills training in correct condom use and negotiation of condom use; taught negotiation skills with role-playing tested for biological outcomes (DiClemente et al., 2004; DiClemente et al., 2009; Jemmott III et al., 2005), and had intense and longer intervention duration of at least > 4 hours with booster sessions and long follow up periods. The incorporation of culture, gender, empowerment, and skills-building components was associated with significant intervention effectiveness.
All the studies measured program impact on one or more of relevant sexual behaviors including: initiation of sex, frequency of sex, number of sexual partners, condom use, STI biological outcomes and multiple measures of sexual risk-behavior (Table 2). The interventions displayed a considerable modification in reported HIV/STI-related risk behaviors, including condom use, alcohol/substance abuse (Stanton et al, 2004), number of sexual partners, and self-efficacy. One intervention resulted in maintenance of reported risk behaviors in the intervention group, with increased reports of sexual risk behavior in the comparison group (Guilamo-Ramos et al., 2011) (Table 1). Jemmott III et al., (2005) established that skill based interventions had a greater effect on behavior change in comparison to HIV/STI information intervention since the skills-intervention participants reported less unprotected sexual intercourse, at the 12-month follow-up.
Initiation of sex is an important measure of sexual activity among the youth. Participants in Guilamo-Ramos et al., (2011) established that the program, in which parents played a great role as mentors, delayed the initiation of sex as compared to the control group at the nine month follow up. The intervention studies established combined measures of sexual activity and condom use including frequency of sex without condoms or number of unprotected sexual partners. They significantly reduced sexual risk taking and /or maintained it. None reported increased sexual risk-behaviors. The effects of the interventions on the frequency of sexual activity for the duration of a definite time interval from three to 24 months before a survey were positive. The measure indicated whether or not participants had sex at all during that period of time. The studies that measured effect on the frequency of sex, reported a reduction in the frequency (Guilamo-Ramos et al., 2011, Jemmott III et al., 2005; Stanton et al., 2004) measured frequency of unprotected sexual intercourse and the frequency of sexual intercourse while intoxicated and there were declines in the frequencies.
The number of participants’ sexual partners was frequently measured during the different follow-up periods. This measure is invaluable for HIV/STI transmission rates. DiClemente et al., (2004); Jemmott III et al. (2005) found a decrease in the number of sexual partners among the intervention group in comparison to the control group. The studies that measured intervention impact on condom use, and all indicated increased condom use; none reported decreased condom use. The interventions that measured biological outcomes only measured STIs and not HIV. DiClemente et al. (2004) and DiClemente et al. (2009) reported significant reductions in chlamydia infections.
Mediating factors are an important factor in the effect of the interventions, and the interventions improved them. The studies that measured impact on beliefs and attitudes regarding any sexual themes were effective in modifying the measured beliefs and attitudes. Interventions that that evaluated effect on perceived peer sexual behavior and norms significantly improved these perceptions. Those studies that measured impact on self-efficacy improved that self-efficacy by strengthening motivation and intention to abstain from sex or restrict the number of sex partners, and increasing intentions and skills to use a condom. Two programs increased communication with parents about sex and had positive consequences (Stanton et al., 2004; Guilamo-Ramos et al., 2011).
Expected outcomes
It was encouraging to find that HIV/STI behavioral interventions were efficacious reducing both self-reported HIV/STI risk sex behaviors and STI rates among African American youth. The effects in these six studies are particularly noteworthy, and are consistent with the expected outcomes. The common characteristics related to the interventions’ impact on various outcomes can be determined, along with aspects of intervention delivery. Each intervention study focused on at least one social or structural risk factor, like the emphasis on gender, and low income urban African American youth, who are high risk, and the utilization of group-based delivery among participants to change social norms. The potential of well-designed interventions to generate changes in HIV/STI related risk behaviors among African American youth by not just relying on HIV/STI knowledge and information, but emphasizing on both reducing risk factors and strengthening protective factors is apparent. The information obtained can be used to recommend additional effective health education programs and materials for health communication among African American youth; recommend public health policies and programs to address prevention needs of the African American youth and inform future preventive efforts.
Implications of findings / outcomes
. Based on the results of the outcome measures, the evaluation of carefully designed interventions tailored towards African American adolescents implies that it is possible to reduce the incidence and prevalence of HIV/STI among African Americans. The findings and expected outcomes of the reviews necessitate a focus on social and environmental determinants of sexual risk taking in intervention approaches aimed at achieving sustained reduction in the incidence and prevalence of HIV/STI. There is a strong implication that the involvement of the individual, parents and community as a whole, is essential to address the incidence and prevalence of HIV/STI among African American youth (Stanton et.al, 2004; Jemmot et al., 2009). Interventions tailored for African American youth facilitated by personnel with experience working with the group and those that addressed multiple risk factors are more likely to have a positive effect on sexual behavior. While the positive effects of some programs lasted only a few months, the effects of some of the interventions indicate sustained behavioral effects (≥ 12 months) suggesting that they can be utilized to change behavior among African American youth and change future HIV/STI prevalence trends (Stanton et al., 2004). The studies also display intervention efficiency since most of them addressed multiple factors using the same program for instance increasing self-efficacy while increasing condom use in one setting.
Since all studies had noteworthy positive results, a few, may have occurred by chance therefore using interventions that address the attitudes, education, behavioral skills, and behavioral skills training can make a difference. The success of the interventions and the various approaches accompanying them relied on the gender, program focus/factors being addressed, age, risk group, parent involvement, access to testing , and sexual experience of the target audience in ways that inform the development of future preventive efforts.
A comprehensive prevention approach tailored for African American youth needs to target more than risky adolescent behaviors since African American adolescents’ individual behaviors do not take place in a vacuum but are influenced by the norms of their family, peers and communities, and by cultural attitudes about sex, as well as the availability of reproductive health care services and prevention education.
Discussion
How findings compare to the literature?
Literature reviewed is consistent with the fact that the African American community including adolescents are at high risk of contracting STI with HIV (KFF, 2012). Numerous researchers have supported a tailored approach for HIV/STI risk reduction interventions contending that they have the highest probability of being successful (Morrison-Beedy et al., 2008). Consequently, there have been many behavioral interventions that have been implemented over the last decade to reduce risk in this population which is surprising because the statistics remain higher for African Americans. Various interventions have proven to be effective over time and can be employed in different settings to change the sexual behavior patterns of adolescents and in turn change course of the high prevalence of HIV/ STIs among the youth and future African American adults. A number of key findings emerge across all reviewed interventions, regardless of setting. Multiple reviews have also demonstrated that behavioral interventions that cover multiple risk behaviors have been more effective in increasing HIV/STI prevention (DiClemente et al., 2011, Pedlow & Carey, 2003, 2004, Stanton, et al., 2004). To completely address the HIV/STI epidemic in African American youth, the literature reviewed implies that preadolescent and adolescent pre-risk interventions that help youth develop the attitudes, knowledge, and skills (condom application and relational) to avoid sexual risk that stem from African American norms and culture need to be noncontroversial, ethically acceptable, and that can be implemented in small and large scale settings ((Pedlow & Carey, 2003; Robin et al., 2004; Ross, Dick, & Ferguson, 2006). Community, youth development and parenting programs can confront pre-risk or risk behaviors in non-controversial ways and assist the youth to attain the essential skills to adapt healthy behaviors and make optimistic life choices.
Altering social norms related to HIV/STI risk and protective behaviors among African American youth is critical since intervention success across studies was distinctly associated with altering beliefs about HIV/STI risk. While some interventions centered on knowledge, skills, and self- value, the findings suggest that the interventions that were most effective were accompanied with activities that concentrated on important behavioral theories and involved parents (Fasula & Miller, 2006, Guilamo-Ramos et al., 2011, Miller et al., 2009, Stanton et al., 2004). Parental involvement seemed to reinforce the interventions. Parent involvement displays the ability to improve and sustain the intervention effect from an adolescent risk reduction intervention. The results are consistent with indicators that validate the importance of parents during the adolescent years.
Together, abstinence and safe sex interventions can reduce HIV/STI sexual risk behaviors, however, safe sex interventions may be remarkably effective with sexually experienced adolescents and may have prolonged effects. Abstinence intervention emphasized postponing sexual intercourse or decreasing its occurrence (Morrison-Beedy et al., 2008). Equally abstinence and safer-sex interventions can reduce HIV/STI sexual risk behaviors, but safer-sex interventions could be more effective with sexually experienced adolescents and may have longer-lasting effects consistent with literature reviewed (DiClemente et al, 2004, 2011).
Interventions need to be culturally tailored to the target population to maximize effectiveness (Romero et al., 2011, Sznitman et al., 2011a). According to Walcott, Meyers, and Landau (2008), effective HIV/STI prevention interventions programs must consider developmental and gender issues, as well as cultural norms and values, to effectively meet the prevention needs of the adolescents. A culturally sensitive intervention has the potential to achieve more sustained reductions in sexual risk behavior and can help to enhance the effects of community-based HIV/STI screening (Sznitman et al., 2011a). In most interventions, culturally and developmentally appropriate messages were utilized to enhance HIV/STI preventive beliefs and behavior of high-risk African American adolescents (Pedlow & Carey, 2004; Sznitman et al., 2011a). Consistent with findings from similar prevention studies with a culturally-based emphasis, Turner-Musa et al. (2008); culturally relevant interventions to reduce risky sexual behaviors remain one promising approach to reducing these impacts for African American youth.
A large review of HIV/STI-prevention interventions reported that use of theory frameworks in the development and implementation of interventions was accompanied with better HIV/STI risk behavior change outcomes (Romero et al., 2011). Social learning theory and social cognitive theory were the frameworks most constantly utilized in effective interventions. These interventions also integrated skills building, and made an effort to increase self-efficacy with respect to safer sexual behavior. Health belief Model, theory of gender and power, theory of planned behavior, and theory of reasoned action were also linked with positive change. "Interventions more generally targeted toward increasing resiliency and competencies are emerging as promising approaches to reducing sexual risk behavior" (Robin et al., 2004, p.18). Sexual decision making is a complicated behavior and is influenced by many factors; thus developing skills in other, related areas can reinforce African American youth sexual decision making skills.
With regard to the duration of the intervention, literature indicates that interventions with few sessions are equally as successful at decreasing risk as interventions with several sessions. However; other reviews imply that duration may have an impact in the success of interventions. In this review, interventions with several sessions were some of the most effective (Stanton et al, 2004; Jemmott III et al., 2010).
Project limitations
A quantitative analysis would have given the specific degree of effectiveness of the intervention programs. Establishing the consistency of the effects of the interventions across studies that met the criteria, even though they were all randomized controlled trials was challenging since there was no standard reporting of measured outcomes. Some studies did not provide sufficient statistical information to assess an effect size. The inconsistency limits assessing comparability of findings between the intervention outcomes. In addition, absence of a well-defined reporting of STI interventions reduces the level of certainty with which these interventions could be replicated. Although the effect sizes between interventions across venues could not be compared due to lack of structured reporting across studies, the evidence gathered in this review is promising since it proposes that there are successful interventions that target African American youth in different settings. The review and analysis of the outcomes from African American adolescent HIV/STI interventions generates a number of suggestions that can guide and enhance the development, implementation, and evaluation of future HIV/STI prevention interventions for African American youth.
Lessons learned and the future of HIV/STI prevention interventions
Identification of the characteristics of successful interventions for African American adolescents isolates the features that hold potential for HIV/STI prevention for the adolescents and future adults. Based on the results of the outcome measures, the evaluation of carefully designed interventions tailored towards African American adolescents implies that it is possible to reduce the incidence and prevalence of HIV/STI among African Americans. However, the variations in the scope of interventions that have been researched, the outcome evaluations designs, and the modest effectiveness of some of the interventions, an indisputable conclusion of what would actually work is unlikely. Nevertheless there are vital lessons learned, affording recommendations for future research.
Customizing interventions for African American adolescents
One important lesson learned from this review is that due to socioeconomic factors and cultural norms, interventions targeted specifically for African Americans interventions are more effective in reducing HIV/STI risk behavior. A replication study by Borawski et al. (2009) indicates that intervention programs are more likely to have a positive effect if all activities were implemented as designed and they are implemented in a similar setting and with comparable youth population. In the study, an effective intervention targeting black urban males was implemented in a suburban setting with a diverse population failed reinforcing the advantage of tailoring interventions for a specific population. Targeted interventions recognize that adolescents have diverse cultures, behavioral risk characteristics, developmental levels, and gender differences (Pedlow & Carey, 2004). Targeted interventions are bound to produce the best results when trying to decrease risk behavior.
Focus on the behaviors that are most responsive to change
In most interventions, the risk behavior most prone to change was condom use during sex and the reduction of sexual partners. Some showed favorable outcomes in increasing abstinence, however, this was rare. Future interventions with African American adolescents ought to target behaviors, like condom use, that have been established across various settings to be most responsive to change. Targeting elements of behavior change that are realistic for adolescents to achieve could result in a prevention strategy that improves HIV/STI intervention effectiveness, and encourages sustained change.
Intensify the capacity of HIV/STI intervention programs away from the individual Sales, Milhausen, and DiClemente (2006) cite that public health practice has shifted focus from the adolescent alone to the adolescent embedded in a complex network of peers, relationships, family, and cultural factors that persistently influence their HIV/STI related risk and protective behaviors. Many of the studies reviewed focused primarily on the adolescent, the group dynamics of the intervention programs, and the other factors that affect behavior. Future interventions should be designed utilize group intervention strategies that create an environment favorable to and supportive of adolescents’ adoption and maintenance of HIV/STI preventive habits.
Involve the parents as a behavioral change mediator
Parents have a major role in the course of a child’s development, including the adolescence period. Using parents as part of the intervention to act as a behavioral change mediator can be advantageous. Studies suggest that involving parents assisted in delaying sexual debut, the reduction in the frequency of intercourse, limiting the number of sexual partners, or encourage healthy behaviors, like protected sex, which are major HIV/STI risk factors. Giving parents the tools they need to improve HIV/STI prevention communication with their adolescents may improve outcomes and sustain change. Integrate lasting maintenance approaches into interventions
Another lesson learned from this review is that intervention effects over the course of time. Short-range effects are noteworthy, but lasting effects were not as much. Studies suggest that for behavior modification to be meaningful, it must be sustained. The extent and complexity of factors that have an effect on African American adolescents’ sexual behavior make it difficult to determine if short term HIV/STI preventive modifications analyzed during a risk reduction intervention can be sustained over extended periods of time. It is therefore necessary to develop and include innovative prevention maintenance strategies to sustain, and possibly, strengthen HIV/STI intervention program effectiveness.
Include biological outcomes as a measure of intervention effectiveness
Interventions targeting adolescents have traditionally depended on almost solely on self-reported behavior modification to evaluate the efficiency. Most of the interventions reviewed, indicated that the participants reported their frequency sex and condom use; number of different sexual partners and other measures pre-intervention and post-intervention. On the other hand, some measured biological outcomes consistent with other studies (Sales et al., 2012; Sznitman et al., 2011b). (Sznitman et al., 2011b) states that self-reported data have been critiqued as susceptible to possible reporting biases, flawed recall, and social appeal bias. Whenever relevant and possible future HIV/STI intervention surveys, should take into account the advantage of including biological indicators as an unbiased and measurable outcome assessment of efficiency, especially when sustained reduction of the incidence and prevalence of HIV/STI is the focus.
Well-defined reporting of STI/HIV interventions
This studies included in this review all had variability in the reporting of HIV/STI intervention trials restricting the comparison process. The absence of coordinated reporting diminished confidence level with which the interventions could be evaluated against other interventions, or successfully replicated. Since there is need for reliable interventions targeting African American youth, HIV/STI interventions should have standard reporting guidelines that can offer a plan that may improve analysis of research outcomes by researchers, health workers, and policy makers.
Interpret and propagate effective African American HIV/STI interventions
The results from this review imply that African American adolescents need culturally appropriate messages for the risk reduction approached to be effective. The review has identified mutual characteristics of effective interventions targeted for the population in different settings. The task on hand is shifting from the intervention studies and taking the essential actions towards interpreting the elements of those interventions that have demonstrated success in specific factors and specific settings into practical programs that can be broadly propagated among African American youth in similar settings (Albarracín et al.,2004). In due course, the prevention of HIV/STI infections in adolescents by addressing the root cause of the risk behaviors relies on the development and evaluation of innovative behavior change approaches in addition to the ease in which these interventions can be interpreted and incorporated into practice, community programs, and schools especially among the African American youth most negatively affected by the HIV/STI epidemic. Modifying the implementation of interventions in schools to cater to African American youth will have a greater impact in the incidence and prevalence of HIV/STI since schools have the ability to reach a considerable large number of youth, as opposed to the settings in the review.
Conclusions
This review validates that effective interventions targeting African American youth exist and can be embraced, tailored and implemented effectively. The interventions reviewed cannot solely resolve the incidence and prevalence of HIV/STI since the modestly reduced sexual risk-taking; however, the mutual characteristics suggest that they can modify sexual and protective behaviors and they can be significant elements in larger more widespread programs that can decrease sexual risk-taking behavior to some extent. More thorough analyses of favorable programs need to be done in middle income and rural African American youth since there are gaps in these areas in the existing literature.
The findings suggest that behavioral interventions addressing empowerment issues with culture and gender specific materials and offering sessions for exercising condom use and negotiation skills present effective ways of HIV/STI prevention for African American youth. Researchers should determine which mediating factors have the greatest impact on behavior in the African American community and which educational approaches and activities are most effective at changing these factors. Additional research should focus on the possible impact of prevention strategies that attend to the various factors influencing HIV/STI infection and transmission in this vulnerable population. Comprehensive activities that facilitate the modification of HIV/STI risk behaviors should be regard as an HIV/STI prevention priority for African American youth. Public health organizations, communities and schools should capitalize on evidence based intervention programs that have prior indication of effectiveness with African Americans youth or those integrating the characteristics of successful programs. If the recommendations provided are implemented, the success of these programs and the knowledge of interventions tailored for African American youth will continue to progress and change the future trends of the incidence and prevalence of HIV/STI among African Americans

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