Programmes for black American heterosexuals

More recently, a large meta-analysis of RCTs of behavioural interventions aimed at reducing unprotected sex and STI incidence in heterosexual African-Americans found an overall reduction in sexual-risk behaviour of 25%. This was statistically significant (95% confidence interval, 0.67-0.84), but became less so when participants were followed up more than six months after the end of the trial.¹ Trials using condom use as their outcome reported greater efficacy (37% increase) than ones reporting unprotected sex (21% decrease).

The meta-analysis included 38 RCTs with a combined total of 14,983 participants.

The researchers commented that there was some evidence of publication bias and social desirability bias in these reported outcomes; in other words, negative findings were less common than a statistical analysis might have expected, due both to researchers being less likely to report negative results and participants being less likely to report negative behaviours.

The same bias was not evident in studies considering STI incidence as an outcome, however. The overall effect on reducing STI incidence, which was only reported by ten trials containing 10,944 participants, was 12%, which was not quite statistically significant (95% confidence interval, 0.52-1.07). However when the trial identified as of ‘lowest methodological quality’, a small one containing 53 participants which had a negative outcome, was excluded, the reduction in STI incidence was 18%, which became statistically significant (95% confidence interval, 0.69-0.98).

Furthermore, the effect on STIs became more, rather than less, significant with longer follow-up times: in trials with follow-ups of more than 12 months there was a 23% reduction in STIs among participants.

The meta-analysis found that there was a clear ‘dose response’ in trials, with ones featuring more than one session and more than 160 total hours more effective than average. And it found trials with the following characteristics produced better-than-average results:

• culturally tailored for African-Americans
• delivered exclusively to African-Americans, rather than mixed
• delivered by peers and containing an element of peer education
• containing discussion of social norms
• delivered in community rather than healthcare settings
• containing the opportunity to learn and practise skills such as condom use and safer-sex negotiation.

Given that only trials conducted in the USA were included in the analysis, and with largely only black Americans as participants, some findings may not be generalisable to other countries and populations. For instance, some analyses of trials targeted at other groups have found that delivery in clinical, rather than community, settings works better, as does delivery by professionals rather than peers.

However, the overall efficacies reported are broadly in line with previous meta-analyses of behavioural interventions in gay men, young people, white heterosexuals and intravenous drug users.