Counselling behavioural interventions for HIV, STI and viral hepatitis among key populations: a systematic review of effectiveness, values and preferences, and cost studies.

INTRODUCTION: Key populations (sex workers, men who have sex with men, people who inject drugs, people in prisons and other closed settings, and trans and gender diverse individuals) are disproportionately affected by HIV, sexually transmitted infections (STIs) and viral hepatitis (VH). Counselling behavioural interventions are widely used, but their impact on HIV/STI/VH acquisition is unclear. METHODS: To inform World Health Organization guidelines, we conducted a systematic review and meta-analysis of effectiveness, values and preferences, and cost studies about counselling behavioural interventions with key populations. We searched CINAHL, PsycINFO, PubMed and EMBASE for studies published between January 2010 and December 2022; screened abstracts; and extracted data in duplicate. The effectiveness review included randomized controlled trials (RCTs) with HIV/STI/VH incidence outcomes; secondary review outcomes of unprotected sex, needle/syringe sharing and mortality were captured if studies also included primary review outcomes. We assessed the risk of bias using the Cochrane Collaboration tool, generated pooled risk ratios through random effects meta-analysis and summarized findings in GRADE evidence profiles. Values and preferences and cost data were summarized descriptively. RESULTS: We identified nine effectiveness, two values and preferences, and two cost articles. Meta-analysis of six RCTs showed no statistically significant effect of counselling behavioural interventions on HIV incidence (1280 participants; combined risk ratio [RR]: 0.70, 95% confidence interval [CI]: 0.41-1.20) or STI incidence (3783 participants; RR: 0.99; 95% CI: 0.74-1.31). One RCT with 139 participants showed possible effects on hepatitis C virus incidence. There was no effect on secondary review outcomes of unprotected (condomless) sex (seven RCTs; 1811 participants; RR: 0.82, 95% CI: 0.66-1.02) and needle/syringe sharing (two RCTs; 564 participants; RR 0.72; 95% CI: 0.32-1.63). There was moderate certainty in the lack of effect across outcomes. Two values and preferences studies found that participants liked specific counselling behavioural interventions. Two cost studies found reasonable intervention costs. DISCUSSION: Evidence was limited and mostly on HIV, but showed no effect of counselling behavioural interventions on HIV/VH/STI incidence among key populations. CONCLUSIONS: While there may be other benefits, the choice to provide counselling behavioural interventions for key populations should be made with an understanding of the potential limitations on incidence outcomes.

Changes in sexual behavior following a sex education program in Brazilian public schools.

This paper describes an evaluation of possible changes in sexual behavior in adolescents who participated in a school-based sex education program in selected public schools in four municipalities in the state of Minas Gerais, Brazil. The program is inserted within the context of reproductive rights, deals with risks involved in unsafe sexual practices and focuses on the positive aspects of sexuality. A quasi-experimental design with pre and post-tests and a non-equivalent control group was used to evaluate the intervention. A total of 4,795 questionnaires were included in this analysis. The program succeeded in more than doubling consistent condom use with casual partners and in increasing the use of modern contraceptives during last intercourse by 68%. The intervention had no effect on age at first intercourse or on adolescents' engagement in sexual activities. The sex education program was effective in generating positive changes in the sexual behavior of adolescents, while not stimulating participation in sexual activities.

[Alcohol and illicit drug use and its influence on the sexual behavior of teenagers from Minas Gerais State, Brazil]. / Uso de álcool e drogas e sua influência sobre as práticas sexuais de adolescentes de Minas Gerais, Brasil.

This article summarizes the findings of a survey including 5,981 students from public schools in Minas Gerais State, Brazil. The analysis assessed the influence of drug use on sexual practices. Among the boys engaged in relationships with casual partners who stated having used illicit drugs, 55.7% reported consistent condom use, as compared to 65.4% among those not reporting such habits. Among boys engaged in relationships with stable partners who reported illicit drug use, consistent condom use was reported by 42.7%, versus 64.1% among those not reporting such habits. In the subgroup of boys engaged in stable relationships who did not report illicit drug use, consistent condom use was less frequent among those that used alcohol/cigarettes, compared to those who did not drink or smoke (60.7% vs. 71.1%). Girls were less likely than boys to use condoms consistently, regardless of the nature of their relationships, without a noticeable influence of drug use. Policies to prevent drug abuse, sexually transmitted diseases, and unplanned pregnancy should be fully integrated.

Uso de álcool e drogas e sua influência sobre as práticas sexuais de adolescentes de Minas Gerais, Brasil / Alcohol and illicit drug use and its influence on the sexual behavior of teenagers from Minas Gerais State, Brazil

Os achados provêm de um estudo transversal de 5.981 estudantes de escolas públicas de Minas Gerais, Brasil. Avaliou-se a influência do uso de drogas sobre as práticas sexuais. Dos rapazes com relacionamento casual que referiram ter utilizado drogas ilícitas, 55,7 por cento disseram usar preservativos de forma consistente (em todas as relações sexuais), enquanto entre os que nunca fizeram uso de tais substâncias, esse percentual foi de 65,4 por cento. Entre os rapazes com relacionamento fixo, que utilizaram droga ilícita, o uso consistente de preservativos foi referido por 42,7 por cento, ao passo que, para os que nunca fizeram uso dessas substâncias, esse percentual foi de 64,1 por cento. No subgrupo dos rapazes com parceria fixa que nunca utilizaram drogas ilícitas, o uso consistente do preservativo foi menos freqüente entre os que utilizaram cigarro e/ou álcool do que entre os que não referiram este uso (60,7 por cento vs. 71,1 por cento). As moças apresentaram menor proporção de uso consistente do preservativo do que os rapazes, independentemente do tipo de parceria, sem influência aparente dos padrões de consumo. Os achados sugerem a necessidade de integrar a prevenção do uso de drogas à de infecções sexualmente transmissíveis/gravidez indesejada.

This article summarizes the findings of a survey including 5,981 students from public schools in Minas Gerais State, Brazil. The analysis assessed the influence of drug use on sexual practices. Among the boys engaged in relationships with casual partners who stated having used illicit drugs, 55.7 percent reported consistent condom use, as compared to 65.4 percent among those not reporting such habits. Among boys engaged in relationships with stable partners who reported illicit drug use, consistent condom use was reported by 42.7 percent, versus 64.1 percent among those not reporting such habits. In the subgroup of boys engaged in stable relationships who did not report illicit drug use, consistent condom use was less frequent among those that used alcohol/cigarettes, compared to those who did not drink or smoke (60.7 percent vs. 71.1 percent). Girls were less likely than boys to use condoms consistently, regardless of the nature of their relationships, without a noticeable influence of drug use. Policies to prevent drug abuse, sexually transmitted diseases, and unplanned pregnancy should be fully integrated.

Changes in sexual behavior following a sex education program in Brazilian public schools / Mudanças no comportamento sexual de adolescentes de escolas públicas no Brasil após um programa de educação sexual

This paper describes an evaluation of possible changes in sexual behavior in adolescents who participated in a school-based sex education program in selected public schools in four municipalities in the state of Minas Gerais, Brazil. The program is inserted within the context of reproductive rights, deals with risks involved in unsafe sexual practices and focuses on the positive aspects of sexuality. A quasi-experimental design with pre and post-tests and a non-equivalent control group was used to evaluate the intervention. A total of 4,795 questionnaires were included in this analysis. The program succeeded in more than doubling consistent condom use with casual partners and in increasing the use of modern contraceptives during last intercourse by 68%. The intervention had no effect on age at first intercourse or on adolescents' engagement in sexual activities. The sex education program was effective in generating positive changes in the sexual behavior of adolescents, while not stimulating participation in sexual activities.

Este artigo descreve a avaliação de possíveis mudanças no comportamento sexual de adolescentes que participaram de um programa de educação sexual implementado em escolas públicas selecionadas em quatro municípios de Minas Gerais, Brasil. O programa está inserido no contexto dos direitos reprodutivos, discute os riscos de práticas sexuais inseguras e enfoca os aspectos positivos da sexualidade. Utilizou-se um desenho quase-experimental com pré e pós-teste e grupo controle não-equivalente. Foram incluídos 4.795 questionários na análise dos resultados. O programa conseguiu dobrar o uso consistente do preservativo com parceiro casual e aumentar em 68% o uso de métodos anticoncepcionais modernos na última relação sexual. A intervenção não teve efeito sobre a idade da primeira relação sexual ou na prática de atividades sexuais. Concluindo, o programa foi eficaz em gerar mudanças positivas no comportamento sexual de adolescentes sem antecipar ou estimular a prática sexual.

[Factors associated with access to health services prior to pregnancy by pregnant adolescents]. / Fatores associados ao acesso anterior à gestação a serviços de saúde por adolescentes gestantes.

OBJECTIVE: To assess determinants of access to primary care services prior to pregnancy by pregnant adolescents. METHODS: Theory-based cross-sectional study conducted to examine access to heath services at five dimensions: geographic, economic, administrative, psychosocial and information. There were included in the study 200 first-time pregnant adolescents (aged 10 to 19 years) who attended a primary care unit in the municipality of Indaiatuba, Southeastern Brazil, in 2003. Data was collected using a semi-structured questionnaire applied in face-to-face interviews conducted just before their first pre-natal care visit. Data analyses were performed through Person's chi-square or Fisher's exact test, and by a multivariate logistic regression model including all five dimensions of access. RESULTS: More than half (63.7%) of the adolescents utilized some gynecological care service. Information (43.8%) or psychosocial feelings of embarrassment or fear (37.0%) barriers were the most frequent reasons given for not having sought care before. The main barrier to health service access was related to the psychosocial dimension, reported by 77.0% of the adolescents studied. CONCLUSIONS: Among all barriers to health service access, the most important were those related to the psychosocial dimension. There is a need for new strategies to facilitate access to health services by adolescents, including actions to reduce gender-based barriers taking into consideration sociodemographic characteristics of this population and the relationship they have with their partners.

Fatores associados ao acesso anterior à gestação a serviços de saúde por adolescentes gestantes / Factores asociados con el acceso anterior a la gestación a los servicios de salud por adolescentes gestantes / Factors associated with access to health services prior to pregnancy by pregnant adolescents

OBJETIVO: Analisar os fatores determinantes do acesso de adolescentes gestantes a serviços de atenção primária à saúde, anterior à ocorrência da gestação. MÉTODOS: Estudo transversal baseado em referencial teórico. O acesso a serviços foi analisado em cinco dimensões: geográfico, econômico, administrativo, psicossocial e de informação. Participaram 200 adolescentes primigestas (10 a 19 anos) atendidas em uma unidade básica de saúde do município de Indaiatuba (SP), em 2003. Um questionário com perguntas abertas e fechadas referentes ao acesso ao último serviço de saúde utilizado, anterior à gestação, foi aplicado às participantes no momento de sua primeira consulta de pré-natal. Os dados foram analisados por meio do teste de qui-quadrado de Pearson ou exato de Fisher e por regressão logística múltipla, considerando as cinco dimensões de acesso. RESULTADOS: Mais da metade (63,7 por cento) das adolescentes utilizou algum serviço de saúde para consulta ginecológica...

OBJECTIVE: To assess determinants of access to primary care services prior to pregnancy by pregnant adolescents. METHODS: Theory-based cross-sectional study conducted to examine access to heath services at five dimensions: geographic, economic, administrative, psychosocial and information. There were included in the study 200 first-time pregnant adolescents (aged 10 to 19 years) who attended a primary care unit in the municipality of Indaiatuba, Southeastern Brazil, in 2003. Data was collected using a semi-structured questionnaire applied in face-to-face interviews conducted just before their first pre-natal care visit. Data analyses were performed through Person's chi-square or Fisher's exact test, and by a multivariate logistic regression model including all five dimensions of access. RESULTS: More than half (63.7 percent) of the adolescents utilized some gynecological care service. Information (43.8 percent) or psychosocial feelings of embarrassment or fear (37.0 percent)...

OBJETIVO: Analizar los factores determinantes del acceso de adolescentes gestantes a los servicios de atención primaria a la salud, anterior a la ocurrencia de la gestación. MÉTODOS: Se efectuó estudio transversal basado en referencial teórico. El acceso a servicios fue analizado en cinco dimensiones: geográfico, económico, administrativo, psicosocial y de información. Participaron 200 adolescentes primigestas (10 a 19 años) atendidas en una unidad básica de salud del municipio de Indaiatuba (Sureste de Brasil), en 2003. Se aplicó a las participantes en el momento de su primera consulta pre-natal un cuestionario con preguntas abiertas y cerradas referentes al acceso al último servicio de salud utilizado, anterior a la gestación. Los datos fueron analizados por medio de la prueba de Chi cuadrado de Pearson o exacto de Fischer y por regresión logística múltiple, considerando las cinco dimensiones del acceso...

[Knowledge of pregnant adolescents about reproductive anatomy and physiology in a municipality of Southern Brazil]. / Conhecimento de adolescentes grávidas sobre anatomia e fisiologia da reprodução.

OBJECTIVES: To study knowledge of some aspects of the female reproductive anatomy and physiology and their association with socio-demographic and reproductive "choices" of pregnant adolescents. METHODS: A cross-sectional study was performed with 200 first time pregnant adolescents who attended a public women's health clinic in the municipality of Indaiatuba, Sao Paulo, Brazil. During their first prenatal care visit, face-to-face interviews were conducted using a structured questionnaire and a three-dimensional handmade female model. Bivariate data analyses were performed using Pearson's Chi-square or Fisher's Exact test. Data were also analyzed using multivariate logistic regression models to test for associations of indicators of knowledge of female reproductive anatomy, physiology of female reproductive organs and physiology of reproduction with socio-demographic characteristics and reproductive "choices". RESULTS: The majority had little knowledge of anatomy (55.5%), with external organs more easily identified and placed than the internal; of physiology of reproductive organs (61.0%), and of physiology of reproduction (76.5%). Associations were found between knowledge and age of partner, couple difference of age, maintenance of the relationship with partner after pregnancy, religious affiliation, and level of education. No association was found between indicators of knowledge with use of contraceptives at first intercourse and with intention of having the baby at that time. CONCLUSION: This study addressed the complexity of the relationship between knowledge of reproductive anatomy and physiology and the theme of adolescent pregnancy, and emphasized the need for more contextualized approaches of programmatic contents on sexual education, in view of the intention to reduce early pregnancy.

Conhecimento de adolescentes grávidas sobre anatomia e fisiologia da reprodução / Knowledge of pregnant adolescents about reproductive anatomy and physiology in a municipality of Southern Brazil

OBJETIVOS: Verificar o conhecimento sobre alguns aspectos do aparelho genital feminino, da fisiologia da reprodução e sua associação com características sociodemográficas e "escolhas" reprodutivas em adolescentes gestantes. MÉTODOS: Realizou-se um estudo de corte transversal com 200 adolescentes primigestas, durante a primeira consulta de pré-natal no Ambulatório da Mulher de Indaiatuba, São Paulo. Foram feitas entrevistas face a face, com questionário estruturado e um modelo feminino tridimensional confeccionado artesanalmente para coleta dos dados. Os dados foram analisados utilizando-se os testes Qui-quadrado de Pearson, ou Exato de Fisher, e por regressões logísticas múltiplas, para verificar associações entre indicadores do conhecimento sobre anatomia dos órgãos genitais femininos, fisiologia dos órgãos e da reprodução com características sociodemográficas e "escolhas" reprodutivas. RESULTADOS: A maioria tinha conhecimento insatisfatório sobre anatomia (55,5 por cento), com os órgãos externos sendo identificados com maior facilidade e melhor localizados do que os internos; fisiologia dos órgãos (61 por cento); e aspectos fisiológicos da reprodução (76,5 por cento). Algumas associações significativas foram estabelecidas entre o conhecimento e a idade dos parceiros, diferença de idade do casal, manutenção do vinculo após ocorrência da gravidez, filiação religiosa e escolaridade da adolescente. Não houve associação entre os indicadores de conhecimento estudados com a utilização de método anticoncepcional na primeira relação sexual e a intenção de ter um filho naquele momento. CONCLUSÃO: Este estudo faz emergir a complexidade da relação entre o conhecimento sobre anatomia e fisiologia reprodutivas e a temática da gravidez na adolescência, evidenciando a necessidade de abordagens mais contextualizadas dos conteúdos de programas de educação sexual, quando seu foco for a redução da gravidez precoce.

OBJECTIVES: To study knowledge of some aspects of the female reproductive anatomy and physiology and their association with socio-demographic and reproductive "choices" of pregnant adolescents. METHODS: A cross-sectional study was performed with 200 first time pregnant adolescents who attended a public women's health clinic in the municipality of Indaiatuba, Sao Paulo, Brazil. During their first prenatal care visit, face-to-face interviews were conducted using a structured questionnaire and a three-dimensional handmade female model. Bivariate data analyses were performed using Person's Chi-square or Fisher Exact test. Data were also analyzed using multivariate logistic regression models to test for associations of indicators of knowledge of female reproductive anatomy, physiology of female reproductive organs and physiology of reproduction with socio-demographic characteristics and reproductive "choices". RESULTS: The majority had little knowledge of anatomy (55.5 percent), with external organs more easily identified and placed than the internal; of physiology of reproductive organs (61.0 percent), and of physiology of reproduction (76.5 percent). Associations were found between knowledge and age of partner, couple difference of age, maintenance of the relationship with partner after pregnancy, religious affiliation, and level of education. No association was found between indicators of knowledge with use of contraceptives at first intercourse and with intention of having the baby at that time. CONCLUSION: This study addressed the complexity of the relationship between knowledge of reproductive anatomy and physiology and the theme of adolescent pregnancy, and emphasized the need for more contextualized approaches of programmatic contents on sexual education, in view of the intention to reduce early pregnancy.

Factors associated with safe sex among public school students in Minas Gerais, Brazil / Fatores associados a sexo seguro entre alunos de escolas públicas em Minas Gerais, Brasil

A cross-sectional study was conducted to evaluate factors associated with safe sex among sexually active public school students in Minas Gerais State, Brazil. The study focused on correlations between the variables gender, age, schooling, current grade, ethnicity, religion, importance attributed to religion, mothers' education, prior exposure to any sex education, promotion of juvenile protagonism, and participation by health professionals in school activities and consistent condom use with casual or stable partners and with use of other modern contraceptive methods. Bivariate and multivariate logistic regression analyses were used. Male gender and participation by health professionals in school activities were positively associated with all indicators of safe sex, and maternal schooling of more than eight years was positively associated with consistent condom use with casual and stable partners. Secondary (versus elementary) schooling and age (older) were inversely associated with consistent condom use with casual and stable partners, respectively. Ascribing greater importance to religion and Evangelical religion were negatively associated with use of modern contraceptives in the last sexual intercourse.

Foi realizado um estudo de corte transversal para avaliar fatores associados à prática de sexo seguro entre estudantes sexualmente ativos de escolas públicas de Minas Gerais, Brasil. Estudou-se a associação de sexo, idade, escolaridade, turno, cor da pele, religião e importância dada à religião, educação da mãe, exposição à educação sexual, promoção do protagonismo juvenil pela escola e participação de profissionais de saúde no ensino, com uso consistente de condom com parceiro casual ou fixo, e uso de anticoncepcionais modernos. Utilizou-se análise bivariada e regressão logística multivariada. Ser do sexo masculino e ter envolvimento de profissionais de saúde no ensino estiveram positivamente associados com todos os indicadores de sexo seguro, e uma mãe com mais de oito anos de escolaridade esteve positivamente associado com uso de condom com parceiro fixo ou casual. Ser aluno do Ensino Médio (versus Fundamental) e ser mais velho associaram-se negativamente com uso consistente de condom com parceiro casual e fixo, respectivamente. Dar grande importância à religião e ser evangélico estiveram negativamente associados ao uso de anticoncepcionais modernos na última relação sexual.

Outcomes of three different models for sex education and citizenship programs concerning knowledge, attitudes, and behavior of Brazilian adolescents.

Three different school-based sex education and citizenship programs in public schools in Rio de Janeiro, Belo Horizonte, and Salvador, Brazil, were evaluated in a cross-sectional study comparing knowledge, attitudes, and practices in sexuality, citizenship, and gender issues among adolescents participating in the programs' activities as compared to adolescents enrolled in schools without such programs (controls). Results showed that Salvador's program achieved good results, with significant changes in knowledge on sexuality and reproductive physiology, attitudes regarding citizenship, and current use of modern contraceptives; Rio de Janeiro's program succeeded in improving students' knowledge of reproductive physiology and attitudes towards sexuality; Belo Horizonte's participants showed greater knowledge of reproductive physiology and STI/HIV prevention but had less positive attitudes towards gender issues, while reporting greater sexual activity. The main difference between Salvador's program and the others was the focus on creative and cultural activities; Belo Horizonte's main difference was its lack of interaction with health services and professionals. However, after the evaluation Belo Horizonte reframed its educational strategies and launched a scaling-up process in a joint effort with the health and school systems.

Outcomes of three different models for sex education and citizenship programs concerning knowledge, attitudes, and behavior of Brazilian adolescents

Três programas de educacão sexual e cidadania, em escolas públicas do Rio de Janeiro, Belo Horizonte e Salvador, Brasil, foram avaliados por meio de um estudo de corte transversal, comparando-se adolescentes da 5ª a 8ª série que participaram dos projetos, com adolescentes de escolas não-participantes. Os resultados mostraram que em Salvador houve mudancas significativas no conhecimento sobre sexualidade e fisiologia da reproducão, atitudes em cidadania e no uso atual de anticoncepcionais modernos. No Rio de Janeiro houve mudancas positivas no conhecimento sobre fisiologia da reproducão e melhoria das atitudes em sexualidade; o projeto de Belo Horizonte mostrou um maior conhecimento sobre fisiologia reprodutiva e prevencão das DST/AIDS, atitudes em gênero menos favoráveis e uma maior atividade sexual. A principal característica do projeto de Salvador foi, a centralizacão das acões em atividades culturais. O projeto de Belo Horizonte era o único que não havia estabelecido parceria com o setor da saúde, mas, após a avaliacão, redefiniu sua estratégia de capacitacão e iniciou uma expansão para todo o estado, em uma acão conjunta das Secretarias Estaduais de Saúde e de Educacão.