摘要：Objectives. We examined the effects of a brief counseling intervention designed to reduce HIV risk behaviors and sexually transmitted infections (STIs) among patients receiving STI services in Cape Town, South Africa. Methods. After randomization to either a 60-minute risk reduction counseling session or a 20-minute HIV–STI educational session, patients completed computerized sexual behavior assessments. More than 85% of the participants were retained at the 12-month follow-up. Results. There were 24% fewer incident STIs and significant reductions in unprotected vaginal and anal intercourse among participants who received risk reduction counseling relative to members of the control condition. Moderator analyses showed shorter lived outcomes for heavy alcohol drinkers than for lighter drinkers. The results were not moderated by gender. Conclusions. Brief single-session HIV prevention counseling delivered to STI clinic patients has the potential to reduce HIV infections. Counseling should be enhanced for heavier drinkers, and sustained outcomes will require relapse prevention techniques. Disseminating effective, brief, and feasible behavioral interventions to those at highest risk for HIV infection should remain a public health priority. Although South Africa has less than 1% of the world's population, it accounts for nearly 10% of the global burden of AIDS. It is estimated that currently 5.5 million South Africans (12.3% of the country's total population of 44.8 million) are infected with HIV. 1 A number of different factors probably account for the high incidence of HIV in South Africa, including sexual mixing patterns, social migration, high rates of alcohol abuse, sexual coercion in relationships characterized by gender power imbalances, and delayed rollout of HIV prevention programs. 2 – 5 Perhaps most critical in driving HIV infections are other co-occurring sexually transmitted infections (STIs), which increase susceptibility to HIV by degrading naturally protective mucosal immunological mechanisms, migrating vulnerable cells to the genital tract, and affording HIV a portal of entry into the bloodstream. STIs also facilitate transmission of the virus from HIV-infected partners by increasing their HIV infectiousness. 6 As a result of these factors, in combination with high HIV prevalence rates, South Africans who contract STIs are among the highest-risk populations for HIV infection in the world. 2 Although behavioral interventions have been shown to be effective in reducing sexual risks among STI clinic patients, 7 several of these interventions have relied on multiple group sessions that have proven difficult to implement. 8 , 9 In response to the urgent need for effective, feasible, and affordable interventions designed to prevent HIV among STI clinic patients, researchers have developed brief single-session HIV risk reduction counseling interventions intended for use in both resource-rich 10 – 13 and resource-poor STI clinics. 14 When performed in conjunction with HIV testing, brief prevention counseling has shown promise in reducing sexual risk behaviors and decreasing STIs. 15 , 16 Brief risk reduction counseling has also demonstrated promising outcomes when delivered outside of HIV testing. For example, Crosby et al. 17 examined a single-session personalized counseling intervention for men receiving STI clinic services in the United States. The intervention led to increases in condom use, reductions in unprotected sex, reductions in sexual partners, and 38% fewer new STI diagnoses relative to a standard of care control group. Overall, single-session sexual risk reduction counseling can be as effective as interventions that require multiple sessions and consume far greater resources. 7 , 18 The brief risk reduction counseling intervention reported here is grounded in cognitive–behavioral theories of health behavior change and is designed for use with all STI patients, including those who refuse HIV testing. We previously tested this intervention in a small trial conducted in Cape Town, South Africa. We observed a 63% reduction in unprotected vaginal and anal intercourse over a 6-month follow-up period, compared with the 30% reduction observed in an HIV education control condition. 19 In addition, condom use among participants increased from 65% to 88%. The overall findings were promising and suggested that a brief single-session counseling intervention may be effective in reducing the risk of HIV and other STIs in South Africa. We report the outcomes of a randomized clinical trial designed to test the effects of a brief single-session risk reduction counseling session intended for use in resource-poor STI clinics. We hypothesized that brief theory-based risk reduction counseling sessions would reduce unprotected vaginal and anal intercourse and prevent STIs during 12 months of observation. We also examined potential moderators of the intervention effects. We included participant gender as a factor in the analyses because there are differences in STI risks between men and women, especially given the gender dynamics in sexual relationships and that men ultimately control the use of condoms. We also tested alcohol use and use of other drugs as moderators of risk reduction outcomes because they are known cofactors for HIV transmission risk behaviors in South Africa. 20 , 21
