JOGNN. Sexually Transmitted Infection/HIV Risk Reduction Interventions in Clinical Practice Settings. Nurses who work in women s health recognize that

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1 JOGNN Sexually Transmitted Infection/HIV Risk Reduction Interventions in Clinical Practice Settings Loretta Sweet Jemmott1, John B. Jemmott2, M. Katherine Hutchinson3, Julie A. Cederbaum4, and Ann O Leary5 ABSTRACT Correspondence M. Katherine Hutchinson, PhD, New York University College of Nursing, 246 Greene Street, Room 617E, New York, NY kathy.hutchinson@nyu.edu Keywords translational research HIV prevention women s health sexual risk reduction primary care interventions African American women, particularly those who live in inner-city areas, experience disproportionately high rates of sexually transmitted infections including HIV. As there are currently no preventive vaccines for HIV and most sexually transmitted infections, prevention efforts must focus on behavioral risk reduction. Thus, culturally tailored interventions for African American women are needed to reduce their incidence of sexually transmitted infections including HIV. One place to intervene with inner-city African American women is in primary care settings. Primary care settings have the potential to reach a wide range of women, including those who may not proactively seek sexually transmitted infection/hiv prevention services. However, in order to be feasible for use in clinical settings, sexually transmitted infection/hiv risk reduction interventions must be brief and easily adapted for use with diverse clients in varied practice environments. To date, few brief sexually transmitted infection/hiv prevention interventions have been designed for use with African American women in primary care settings. Only one of these, the Sister to Sister: Respect Yourself! Protect Yourself! Because You Are Worth It! intervention, has demonstrated effectiveness in reducing sexual risk behaviors and sexually transmitted infection incidence. This article describes this 20-minute, one-on-one nurse-led intervention for African American women and discusses considerations for its implementation in primary care and other clinical settings. JOGNN, 37, ; DOI: /j x Accepted November PhD, RN, FAAN, Van Ameringen professor of psychiatric mental health nursing and Director, Center for Health Disparities Research, University of Pennsylvania School of Nursing, Philadelphia 2 PhD, professor, Annenberg School of Communication, University of Pennsylvania, Philadelphia 3 PhD, RN, assistant professor, New York University College of Nursing 4 MSW, MPH, doctoral candidate, University of Pennsylvania School of Social Policy & Practice, Philadelphia Nurses who work in women s health recognize that sexually transmitted infections (STIs) including HIV are major causes of morbidity and mortality in the United States, particularly among women. As such, reducing STIs/HIV is a national health priority. Although all sexually active women are at risk for STIs including HIV, African American women experience disproportionately high rates of HIV and many other STIs. Those who reside in the poorest urban areas often experience the greatest risk and highest rates of STIs/HIV ( Centers for Disease Control and Prevention [CDC], 2002b; Eng & Butler, 1997; Gillespie, Kadiyala, & Greener, 2007; Jemmott, Jemmott, & Hutchinson, 2001 ). Sexually transmitted infections/hiv can be prevented by changing sexual risk behaviors. Considerable evidence indicates that behavioral interventions are effective in reducing self-reported STI/HIV sexual risk behaviors (see Exner, Seal, & Ehrhardt, 1997; Mize, Robinson, Bockting, & Scheltema, 2002; Neumann et al., 2002; Semaan et al., 2002 ). However, relatively few randomized controlled trials have tested the long-term effects of such interventions on inner-city African American women ( Jemmott, Jemmott, & O Leary, 2007; Sterk, Theall, & Elifson, 2003; Wingood & DiClemente, 1996, 2000 ). When effective HIV interventions are identifi ed, one important concern that arises is whether these interventions are disseminated to likely end users nurses and others who work with women in clinical and community settings. Hence, the purposes of this article were to: (a) review the extent of the problem of STIs, including sexually transmitted HIV infection, among inner-city African American women; (b) describe an effective, nurseled 20-minute STI/HIV risk reduction intervention for African American women that can be implemented in primary care settings; and (c) highlight the nursing implications and strategies for effective implementation of this intervention in clinical practice settings , AWHONN, the Association of Women s Health, Obstetric and Neonatal Nurses 137

2 HIV/STI Risk Reduction Interventions African American women are disproportionately affected by STIs and HIV. Sexually Transmitted Infections/ HIV Among African American Women African American inner-city women are disproportionately impacted by STIs, including HIV and AIDS ( CDC, 2004 ). Only 13% of the nation s population is categorized as African American ( McKinnon, 2003 ), yet 49% of AIDS cases have occurred among African Americans ( CDC, 2007 ). African American men represent about 44% of HIV/AIDS cases among adolescent and adult men, while African American women account for 68% of the cumulative HIV/AIDS cases reported among females ( CDC, 2006a ). Cumulative incidence rates for AIDS are more than 23 times higher among African American women than White women ( CDC, 2006b ). In sum, African American women represent one of the fastest growing subgroups of new HIV/AIDS cases. Inner-city African American women also have disproportionately higher rates of chlamydia, syphilis, gonorrhea, and pelvic inflammatory disease ( CDC, 2006c ). Women with higher rates of STIs are, in turn, at increased risk for HIV infection ( Aral, Hawkes, Biddlecom, & Padian, 2004 ). The presence of an STI and any associated lesions may facilitate transmission of HIV (Aral et al.). In inner-city areas most affected by poverty, drug use, and lack of resources, STI and HIV rates are often much higher than in more affl uent areas ( CDC, 2000 ). For example, of the 30,962 cases of AIDS in Pennsylvania, 74.8% reside in the city of Philadelphia ( Philadelphia Department of Public Health, 2005 ). Within Philadelphia, the highest AIDS rates are found within the poorest areas of the city (Philadelphia Department of Public Health, 2005). Rates for many other STIs show similar distributions. For example, in 2004, rates of chlamydia in Philadelphia county were greater than 300/100,000 population ( CDC, 2005 ). Risk for sexually transmitted HIV infection and other STIs can be reduced by changes in sexual behaviors. The most effective way for African American women to avoid STIs including HIV is to reduce exposure by reducing sexual activity, reducing numbers of partners, avoiding partners who are IDUs, and using condoms. Among sexually active women, failure to use condoms is perhaps the most common STI/HIV risk associated behavior among women of childbearing age ( Manhart & Holmes, 2005; Mayaud & McCormick, 2001 ). HIV Risk Reduction Intervention Research Progress has been made in the development of HIV risk reduction interventions ( Pequegnat & Stover, 2000 ). Several phase III randomized controlled trial efficacy studies have demonstrated that behavioral interventions can reduce HIV risk associated behavior and theory-based determinants of such behavior among adult women ( Ehrhardt et al., 2002; Fisher et al., 2006; Gollub, French, Latka, Rogers, & Stein, 2001; Hobfoll, Jackson, Lavin, Johnson, & Schroder, 2002; Jemmott et al., 2007; Kamb et al., 1998; Lauby, Smith, Stark, Person, & Adams, 2000; O Leary & Wingood, 2002; Peragallo et al., 2005; Shain et al., 1999; Sikkema et al., 2000 ). These intervention studies were conducted in a variety of sites; some took place in housing developments and other community sites, while others targeted health clinics. These studies demonstrated signifi cant changes in sexual risk behavior, including increases in condom use ( Fisher et al., 2006; Kamb et al., 1998; Peragallo et al., 2005; Sikkema et al., 2000 ) and reductions in unprotected sexual intercourse ( Fisher et al., 2006 ; Gollub et al.; Shain et al., 1999 ) among women who received HIV risk reduction interventions as compared with those in control groups. In addition to behavior changes, four of these randomized controlled trials demonstrated that sexual risk reduction interventions could result in reductions in biologically confi rmed STI rates among women (Hobfoll et al.; Jemmott et al., 2007; Kamb et al., 1998; Shain et al., 1999 ). 5 PhD, senior behavioral scientist, Prevention Research Branch, Division of HIV/AIDS Prevention, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA The prevalence of intravenous drug use and intravenous drug users (IDUs) in urban areas greatly heightens the risk of HIV infection for African American women who reside in these environments. Although the women themselves may not use drugs, they may have sexual relationships with men who are IDUs. Those women who use drugs themselves, even noninjected drugs such as cocaine and crack, experience elevated risk for STIs and HIV due to higher rates of sexual risk behaviors, unprotected sex, multiple partners, and exchanging sex for drugs and money ( Coyle, 1998; Kral, Bluthenthal, Booth, & Watters, 1998; Lally et al., 2002 ). Participants in two of these studies were selected based on recent STI or HIV test results ( Kamb et al., 1998; Shain et al., 1999 ). Whether the fi ndings of these trials would generalize to a less restricted population of women is unclear. Furthermore, three of the studies involved multiple sessions ( Hobfoll et al., 2002; Kamb et al., 1998; Shain et al., 1999 ), and two of the studies were implemented in a group format (Hobfoll et al.; Shain et al., 1999 ). Multiple-session and group format interventions may require extensive time commitments on the part of both clients and staff and can be labor intensive and diffi cult to schedule, thus making them 138 JOGNN, 37, ; DOI: /j x

3 Jemmott, L. S., Jemmott, J. B., Hutchinson, M. K., Cederbaum, J. A., and O Leary, A. P RINCIPLES & P RACTICE impractical and diffi cult to implement in primary care and clinical settings. Only two of the effective intervention studies were implemented using an individualized one-on-one format ( Kamb et al., 1998; Jemmott et al., 2007 ). Of these two, only one study involved brief single-session intervention that lasted 20 minutes implemented by health care providers with African American women in primary care settings ( Jemmott et al., 2007 ). Sister to Sister Respect Yourself! Protect Yourself! Because You Are Worth It! STI/HIV Intervention Model The Sister to Sister Respect Yourself! Protect Yourself! Because You Are Worth It! ( Sister to Sister ) intervention model provides African American women with the information, motivation, and skills necessary to change their behaviors in ways that reduce their risk of contracting HIV and other STIs ( Jemmott et al., 2007 ). The curriculum was tailored to the needs of inner-city African American women based upon information gathered from elicitation surveys and focus groups conducted with group members. Framed within the Social Cognitive Theory ( Bandura, 1986 ) and the Theory of Planned Behavior ( Ajzen, 1991 ), the curriculum targets inner-city African American women s behavioral beliefs about the consequences of protective and risky sexual behaviors and their control beliefs about factors that would facilitate or thwart their performance of such behaviors. The Sister to Sister STI/HIV risk reduction intervention is designed to be educational but engaging, culturally sensitive, and gender appropriate. The intervention incorporates the Respect Yourself! Protect Yourself! Because You Are Worth It! theme, which encourages women to respect and protect themselves for themselves, their families, and their communities ( Jemmott et al., 2007 ). Unique Themes Three themes provide the Sister to Sister Respect Yourself! Protect Yourself! Because You Are Worth It! curriculum with a unique approach that has been successful with inner-city African Americans. These three themes are particularly salient to African American women and include as follows: Family and Community. The intervention emphasizes the theme, Let s work together to save our people and our community. The curriculum emphasizes how HIV and AIDS have affected families and communities and the importance of protecting family and community as a motive to change an individual s risk-associated behaviors. The theme contrasts with the more simplistic focus on individual-level attitudes and beliefs. It focuses on participants needs to adopt responsible sexual behavior to prevent the sexual transmission of HIV for the sake of their families, sexual partners, and the larger African American community. Use of a condom keychain helps take the message and theme from the individual encounter in the clinical setting to the community by providing a tool to elicit conversations with partners, family, and friends. Caring. A second key theme in the curriculum is the empowering message of caring about self, about the future, about family, and about one s community. In addition, it stresses that we, as nurses, also care about individuals and communities and have a stake in helping individuals make safer sexual choices. The curriculum emphasizes how caring can lead to respecting and protecting oneself and one s family. Activities are designed to build self-effi cacy and confi dence to engage in safer sex behaviors in a caring and supportive manner. To build self-effi cacy, the intervention emphasizes that you can do it, you have the love of self and family, you have the skills and the confi dence to do it, and we believe in you. This sense of self-effi cacy is reinforced in role-play scenarios. Self-Worth. The third key theme in the curriculum is selfworth. Sometimes women struggle with such issues as self-esteem, self-respect, and self-pride. The overriding theme Respect Yourself! Protect Yourself! Because You Are Worth It! emphasizes that it is important that women feel good about themselves, their decisions, and their behaviors. Women learn that having safe sex is a choice that each person makes at some point in her life. The curriculum emphasizes that this choice should be based upon how an individual feels about herself and the potential adverse consequences of unprotected sex, including HIV, other STIs, and unintended pregnancy. The curriculum emphasizes that African American women are beautiful, they are loved, they are valued and needed, and they are worth it! The curriculum addresses these feelings by emphasizing that it feels good to respect yourself, protect yourself, and make responsible safer sexual choices. Brochures, role-play scenarios, and skill-building condom activities bolster and reinforce the women s sense of pride, self-confi dence, and self-satisfaction. Intervention Description and Content The Sister to Sister intervention consists of a single, one-on-one 20-minute session between a client and a nurse facilitator that stresses the importance of using condoms to reduce the risk of STIs and HIV. The Sister to Sister Respect Yourself! Protect Yourself! Because You Are Worth It! intervention model expands usual clinic-based counseling strategies to include the use of JOGNN 2008; Vol. 37, Issue 2 139

4 HIV/STI Risk Reduction Interventions videos, condom demonstrations, and client role-plays to support client behavioral change through skill practice and demonstration in an individualized format. It is designed to: (a) increase knowledge of HIV/AIDS and STIs, (b) strengthen behavioral beliefs regarding the ability of condoms to prevent STIs and HIV, (c) enhance hedonistic beliefs regarding effects of condom use on sexual enjoyment, and (d) increase communication skills, condom use skills, and condom use self-efficacy so that women can negotiate condom use with their sexual partners. To increase confi dence and skills, the curriculum employs brochures, video clips, condom demonstrations, practice with an anatomic model, and role-playing condom use or refusal of unsafe sex. The intervention is highly structured and implemented by facilitators using intervention manuals. It is educational, engaging, and gender appropriate and involves videos, brainstorming, experiential exercises, and skill-building activities. The Sister to Sister intervention is conducted by a nurse facilitator who has been trained in how to implement the intervention. The session begins with an HIV/ STI risk assessment interview. The facilitator then uses data collected during the assessment to tailor her comments to meet the specifi c needs of the individual participant. This includes a review of the Sister to Sister HIV/STI prevention brochure, which provides an overview of the beliefs and behaviors that lead to sexual risk for HIV/STIs. Curriculum activities are designed to help women recognize that faulty reasoning and decision making can increase their risk of HIV infection. The activities help women to understand the adverse consequences of participating in unsafe sexual activity and the positive consequences of safer sexual practices, including abstinence. The facilitator engages the women in activities to increase comfort with condom use and to allay common concerns about the negative effects of condom use on sexual enjoyment and spontaneity. Participants handle condoms and practice using condoms correctly. A condom keychain is also provided to all participants. This serves a dual function: it holds a usable condom so that a woman is always able to protect herself and provides a prompt for discussions outside the clinical setting with partners, family members, and friends. Thus, the keychain provides access to a condom a sign to partners that a woman values her sexual health, and strengthens community by increasing communication about safer sex behaviors. Two brief video clips evoke feelings, thoughts, attitudes, and beliefs about HIV/AIDS and sexual risk behavior while highlighting prevention skills. Women also participate in brief role-playing scenarios that allow them to observe, analyze, and practice the skills of negotiating abstinence or condom use in a variety of circumstances. Role-play allows the woman to practice talking to her partner about using condoms as well as brainstorm strategies with the facilitator about easing communication regarding condom use negotiation. One of the techniques learned throughout the intervention is the SWAT ( S ay No Effectively, W hy, A lternative, and T alk it Out) (for more specifi c curriculum content contact Select Media, Inc.; ). SWAT is used in the role-plays to empower women to believe that they are deserving of safe sexual encounters, respectful of their own values, and that their sexual health is worth protecting. This again emphasizes the theme of self-worth and caring about self and one s community. Facilitators provide constructive feedback and support during and after each role-play scenario. The intervention concludes with a powerful closing statement from the facilitator intended to empower women to go forward and use what they know to protect themselves. The specifi c content of the brief, one-on-one Sister to Sister intervention is outlined in Table 1. Effectiveness of the Brief Interventions Jemmott et al. (2007) recently evaluated the effectiveness of the Sister to Sister, brief one-on-one HIV/STI risk reduction intervention as part of a larger randomized controlled trial study. The objective of the study was to evaluate the effectiveness of four theory-based interventions designed for use in primary care settings. The study compared and contrasted two types of intervention skill building versus information only, and two methods of intervention delivery group versus individual (one-on-one). The Sister to Sister, one-on-one brief curriculum described above served as the skill-building individual intervention in the study. The study participants were 564 Black women (mean age 27.2 years) seeking care at the outpatient Women s Health Clinic of a large hospital in Newark, New Jersey. Participants were randomly assigned to one of the fi ve single-session interventions: 20-minute, one-on-one HIV information intervention; 20-minute, one-on-one HIV behavioral skill training intervention; 3.33-hour group HIV information intervention; 3.33-hour group behavioral skill training HIV intervention; and 3.33-hour group control intervention on health issues unrelated to sexual behavior. The effectiveness of the four interventions was ascertained by comparing changes in sexual risk behaviors and STI rates between participants in the intervention and control groups. Differences between the intervention groups were also assessed ( Jemmott et al., 2007 ). Participants completed confi dential questionnaires at baseline, immediately postintervention, and at 3-, 6-, and 12-month follow-ups. At baseline and at 6- and 140 JOGNN, 37, ; DOI: /j x

5 Jemmott, L. S., Jemmott, J. B., Hutchinson, M. K., Cederbaum, J. A., and O Leary, A. P RINCIPLES & P RACTICE Table 1: Sister to Sister Respect Yourself! Protect Yourself! Because You Are Worth It! : One-on-One Intervention Modules Goals and Objectives Description of Selected Activities and the Specially Designed Brochure Module 1: Introduction and overview Module 2 Module 3: The risk assessment inventory Module 4: Teach content using the Sister to Sister brochure Module 5: Condom information and condom use Module 6: Injection drug use Module 7: Negotiation skills and video clip Module 8: Role-play Goal to provide the woman with a general overview of the program and foster excitement and enthusiasm about their participation. Goal to reinforce information on women and STIs and HIV/AIDS and to increase perceived risk of HIV infection. Goal to assess her personal risk of STI/HIV infection. Goal to increase knowledge on STIs and HIV/AIDS. Goal to increase knowledge and skills on the correct steps for using a condom and how to make them fun and pleasurable. Goal to increase knowledge and skills on the correct steps in cleaning injectable drug use works and reinforces the need to not share injection drug use works. Goal to build self-effi cacy and skills in negotiating condom use with her partners. Goal to reinforce skill and comfort in discussing condom use with her partners. It includes a description of the program and statistics of women and sexually transmitted infections (STIs) and HIV/AIDS in their community. It includes the AIDS Changing the Rules video clip, which depicts a woman who has been infected with HIV by having sex with her husband. More information is presented about women and AIDS in their community and why they are infected. The nurse asks the woman a series of questions from the HIV risk assessment inventory about their own risk behaviors and that of their sexual partners. The nurse covers the information on the brochure, including HIV/AIDS, why women get STIs and HIV/AIDS, what behaviors place women at risk for HIV/AIDS, and myths and facts about HIV/AIDS. The nurse asks a series of questions about knowing how to buy condoms and past condom use behaviors. Then, the woman learns and practices how to use condoms correctly on an anatomic penis model. Using the brochure, she teaches good things about using condoms, where to get condoms, and how to make condom use fun and pleasurable. A discussion follows on whether she will use condoms. Using the brochure, the nurse teaches the correct steps on how to clean their works followed by a discussion on the importance of not sharing their injection equipment. It provides ways to share this information with people they know who inject drugs. A discussion begins with can you talk to your partner about using condoms, what do you think he will say, what will his reaction be? They watch the video clip Let s do something different. Afterward, they discuss the woman s strategies for discussing condoms and discuss their own concerns about using condoms. Using the brochure, they learn the strategies for talking to their partner about condom use. The participant practices talking to her partner about using condoms with role-play scenarios. In the fi rst role-play, the nurse will be the woman and the woman will role-play her sexual partner. In the second role-play, they switch roles. It concludes with a nurse shaking the woman s hand and giving her a powerful Sister to Sister Respect Yourself! Protect Yourself! Because You Are Worth It! statement. 12-month follow-ups, cervical swab specimens were obtained from participants and tested for Neisseria gonorrhoeae and Chlamydia trachomatis using the Gen-probe pace-2 system (Gen-Probe, Inc., San Diego, CA). Those who tested positive for STIs were treated following CDC guidelines for single-dose antimicrobial therapy ( CDC, 2002a ). The results of the study demonstrated that the Sister to Sister, one-on-one brief skill-building intervention and the group skill-building intervention were both effective at reducing sexual risk behaviors and STI occurrence and that these effects were sustained at 12-month follow-up ( Jemmott et al., 2007 ). Women in the brief skill-building interventions reported greater frequency of condom use at 12-month follow-up compared to women in the control group ( d =.24, p =.03). These women also were more likely to report using condoms the last time they had sex compared to those in the control group ( d =.20, p =.034) and were less likely to test positive for STIs at the 12-month follow-up ( d =.20, p =.03) ( Jemmott et al., 2007 ). The skill-building interven - tions resulted in positive changes on mediators of condom use (hedonistic beliefs, self-effi cacy, and impulse control). The authors concluded that brief, nurse-led, one-on-one, and group skill-building interventions were effective in reducing STI/HIV sexual risk behaviors and STI incidence among inner-city African American ( Jemmott et al., 2007 ). Another signifi cant fi nding was that the skill-building group intervention did not produce outcomes superior to the one-on-one intervention ( Jemmott et al., 2007 ). Contrasts between the effectiveness of the group and one-on-one skill-building interventions on sexual risk outcomes were not signifi cant as follows: condom use at last sexual intercourse at 3-, 6-, and 12-month followups ( p =.48,.13, and.80, respectively); frequency of unprotected sexual intercourse at 3-, 6-, and 12-month follow-ups ( p =.69,.67, and.58, respectively); and STI occurrence at 6- and 12-month follow-ups ( p =.45 and.82, respectively) ( Jemmott et al., 2007 ). This fi nding JOGNN 2008; Vol. 37, Issue 2 141

6 HIV/STI Risk Reduction Interventions A brief, theory-based, culturally sensitive 20-minute intervention demonstrated effectiveness in reducing STI/HIV sexual risk behaviors and STI rates among inner-city African American women. was somewhat surprising as the group intervention was considerably longer than the one-on-one intervention and participants in group skill-building activities might be expected to benefi t from modeling and feedback from other group members. However, the individually delivered skill-building intervention may have drawn out more personal admissions by participants. Furthermore, skill-building activities in the one-on-one intervention may have been more customized to the specifi c risks and needs of the individual women ( Jemmott et al., 2007 ). Nursing Implications: Translating Effective Research Interventions Into Clinical Practice Primary care settings provide an ideal environment in which to implement STI/HIV prevention interventions for African American women. In primary care settings, it is possible to reach a wide range of women, including those who may not recognize their risk for STIs/HIV and may not proactively seek STI/HIV prevention services. Although most behavioral risk reduction interventions last four or more hours and involve multiple sessions, brief single-session interventions may be more practical for use in primary health care settings. The Sister to Sister brief intervention developed for primary care settings by Jemmott et al. (2007) was shown to reduce STI/ HIV sexual risk behaviors and STI incidence among inner-city African American women. This research-based intervention is now ready for dissemination, implementation, and further evaluation when used by practitioners in clinical practice settings. Initiatives to Translate Evidence-Based Interventions Into Clinical Practice The CDC has three initiatives to replicate and disseminate effective programs: turning research into practice. The fi rst initiative Replicating Effective Programs (REP) is a 2-year initiative designed to create active partnerships among researchers, prevention agencies, and communities at all stages of research and transfer into practice. The fi rst goal of this initiative is to promote the use of HIV risk reduction interventions that are science based by HIV prevention agencies. The second goal is to ensure that research-based HIV prevention behavioral interventions are made available for use by prevention agencies. Thus, the REP project converts interventions into packages (kits) for use by local HIV prevention agencies. The third goal of the initiative is to promote collaboration between researchers and community advisors to prepare the intervention packages. In 2006, the Sister to Sister HIV risk reduction intervention was selected to be included. Centers for Disease Control and Prevention s second dissemination initiative program is entitled, the National Dissemination of Evidenced-Based Interventions (DEBI). The goal of the DEBI project is to develop and coordinate a national-level strategy to provide training, technical assistance, and other capacity-building activities to disseminate evidenced-based HIV interventions to state- and community-level HIV prevention programs. The third CDC initiative is their project to replicate and extend the proven interventions. The Sister to Sister STI/HIV prevention intervention was also selected for this project. In 2005, the CDC announced a new request for proposals entitled, Adaptation and Evaluation of a Brief, Nurse-Delivered Sexual Risk Reduction Intervention for HIV Positive Women in the South PSO The RFP targeted Departments of Health in the southern region. The grant was awarded to the University of North Carolina, Chapel Hill, School of Nursing to be implemented in the North Carolina s state health departments. Implications for Nurses Nurses are key health professionals in primary care settings units. They know the populations with whom they work; many provide direct care and counseling to innercity African American women. Furthermore, nurses possess the skills necessary to effectively educate and counsel women about sexual health issues and sexual risk reduction. They are knowledgeable about the etiology, transmission, and prevention of STIs including HIV and are aware of the skills their clients need to prevent STI/HIV transmission. Nurses in primary care settings have contact with women who are at risk for STIs including HIV but who might not otherwise have access to or seek out testing, treatment, prevention counseling, and/ or other STI/HIV prevention services. As such, primary care nurses are uniquely positioned to reach at-risk and underserved populations and assist them to reduce their STI/HIV related sexual risk behaviors. In order to maintain program effectiveness, it is vitally important to maintain the integrity of interventions. One potential threat to the integrity of the interventions lies in the nurse facilitators who implement the intervention. Nurses are individuals with different personalities and different styles of facilitation. These differences could lead to differential implementation of the same intervention and result in variations in program effectiveness. To minimize this possibility, the intervention is structured, manuals are used, and those who will implement the 142 JOGNN, 37, ; DOI: /j x

7 Jemmott, L. S., Jemmott, J. B., Hutchinson, M. K., Cederbaum, J. A., and O Leary, A. P RINCIPLES & P RACTICE intervention, the nurse facilitators, are trained to implement them correctly. In order to successfully implement an intervention like Sister to Sister, nurse facilitators need to learn the goals and purposes of the intervention and have opportunities to practice implementing the interventions and receive feedback from others. Nurse facilitators are usually trained in small groups. During training, nurse facilitators participate in all the activities that participants experience during intervention sessions, including video and role-play activities. Nurse facilitators take turns acting as facilitators and clients in practice sessions. Using this process, nurse facilitators can identify problems that might arise during implementation and discuss ways of resolving them with facilitator trainers. In addition, nurses should be actively involved in deciding how, when, and where to implement brief, oneon-one skill-building interventions in their practice settings. One-on-one sessions may be easily incorporated into routine practice when women are escorted to examination rooms or private offi ces. One-on-one sessions require little time, about 20 minutes, and are ideal for settings providing episodic care, where women may not be seen again for long periods of time. In contrast, the brief, small group skill-building risk reduction intervention, while equally effective, requires over 3 hours to implement. Although not the focus of the current article, this type of curriculum would be better suited for use in settings where groups of women are scheduled for extended periods of time at regular intervals (e.g., scheduled support group or group therapy sessions). Although African American registered nurses were used to implement the brief interventions in the original study, previous studies by Jemmott and her associates have demonstrated that the effectiveness of HIV risk reduction interventions can be maintained, independent of the race of the facilitator, provided that the facilitator is properly trained in both the intervention and the provision of culturally sensitive and culturally competent care ( Jemmott & Jemmott, 1991, 1992 ). Practitioners should consider their usual scheduling practices and patient populations in deciding which type of skill-building intervention (one-on-one or group) is better suited and more easily adapted for use in their practice settings and in choosing the most appropriate individuals to implement STI/HIV risk reduction interventions. Conclusions Nurses can incorporate brief one-on-one interventions into the routine practice of their primary care and women s health clinical practice settings. The results of the Sister to Sister intervention demonstrated that culture-sensitive, theory-based, skill-building interventions can reduce HIV risk associated sexual behavior and STIs among African American women. The brief, single-session one-on-one 20-minute interventions were shown to be feasible for use in primary care and other clinical practice settings and as effective as group skill-building interventions that were much longer in duration ( Jemmott et al., 2007 ). As inner-city African American women continue to be disproportionately affected by STIs including HIV, primary care settings present unique opportunities for providing risk reduction interventions to high-risk women. However, such interventions need to be cost effective, practical, and easily adaptable for practice settings. As shown, the brief skill-building intervention developed by Jemmott et al. (2007) has demonstrated effectiveness in improving condom use and reducing the incidence of STIs among urban African American women in primary care settings. Most importantly, these behavior changes were sustained for up to a year following the brief intervention. Clearly, many African American women can benefi t from nurses implementing brief individualized risk reduction interventions that provide opportunities for practicing condom use and sexual negotiation skills, which may contribute to reducing the spread of STIs including HIV. Acknowledgments Supported by Grant R01 NR03123 from the National Institute for Nursing Research. REFERENCES Ajzen, I. ( 1991 ). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50, Aral, S. O., Hawkes, S., Biddlecom, A., & Padian, N. ( 2004 ). Disproportionate impact of sexually transmitted diseases on women. Retrieved October 14, 2005, from EID/vol10no11/ _02.htm Bandura, A. ( 1986 ). 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