Lisa Romero

The effectiveness of group-based comprehensive risk-reduction and abstinence education interventions to prevent or reduce the risk of adolescent pregnancy, human immunodeficiency virus, and sexually transmitted infections: two systematic reviews for the Guide to Community Preventive Services.

CONTEXT Adolescent pregnancy, HIV, and other sexually transmitted infections (STIs) are major public health problems in the U.S. Implementing group-based interventions that address the sexual behavior of adolescents may reduce the incidence of pregnancy, HIV, and other STIs in this group. EVIDENCE ACQUISITION Methods for conducting systematic reviews from the Guide to Community Preventive Services were used to synthesize scientific evidence on the effectiveness of two strategies for group-based behavioral interventions for adolescents: (1) comprehensive risk reduction and (2) abstinence education on preventing pregnancy, HIV, and other STIs. Effectiveness of these interventions was determined by reductions in sexual risk behaviors, pregnancy, HIV, and other STIs and increases in protective sexual behaviors. The literature search identified 6579 citations for comprehensive risk reduction and abstinence education. Of these, 66 studies of comprehensive risk reduction and 23 studies of abstinence education assessed the effects of group-based interventions that address the sexual behavior of adolescents, and were included in the respective reviews. EVIDENCE SYNTHESIS Meta-analyses were conducted for each strategy on the seven key outcomes identified by the coordination team-current sexual activity; frequency of sexual activity; number of sex partners; frequency of unprotected sexual activity; use of protection (condoms and/or hormonal contraception); pregnancy; and STIs. The results of these meta-analyses for comprehensive risk reduction showed favorable effects for all of the outcomes reviewed. For abstinence education, the meta-analysis showed a small number of studies, with inconsistent findings across studies that varied by study design and follow-up time, leading to considerable uncertainty around effect estimates. CONCLUSIONS Based on these findings, group-based comprehensive risk reduction was found to be an effective strategy to reduce adolescent pregnancy, HIV, and STIs. No conclusions could be drawn on the effectiveness of group-based abstinence education.

Trends in Human Immunodeficiency Virus– and Sexually Transmitted Disease–Related Risk Behaviors Among U.S. High School Students, 1991–2009

BACKGROUND People who engage in unprotected sexual intercourse or use injection drugs are at increased risk for HIV infection and sexually transmitted diseases (STDs). Monitoring changes in behaviors over time can provide information about the effectiveness of new policies and programs. PURPOSE To measure trends in HIV- and STD-related risk behaviors among high school students in the U.S. during 1991-2009. METHODS Nationally representative data from the 1991-2009 biennial national Youth Risk Behavior Surveys were analyzed to describe trends in HIV- and STD-related risk behaviors. For each cross-sectional national survey, students completed anonymous, self-administered questionnaires assessing risk behavior participation. This study was approved by the CDC IRB, and parental permission was obtained. To assess the significance of time trends for each behavior, logistic regression analyses were conducted that controlled for gender, grade, and race/ethnicity and simultaneously assessed linear and quadratic effects. Data were analyzed in 2010. RESULTS During 1991-2009, decreases were observed in the percentage of U.S. high school students who ever had sexual intercourse, had multiple sex partners, and who were currently sexually active. The prevalence of condom use increased during 1991-2003 and then leveled off during 2003-2009. However, these changes in risk behaviors were not observed in some gender and racial/ethnic subgroups. CONCLUSIONS Additional efforts to reduce HIV- and STD-related risk behaviors, particularly among black and Hispanic students, must be implemented to decrease rates of HIV infection and STDs.

Reduced Disparities in Birth Rates Among Teens Aged 15–19 Years — United States, 2006–2007 and 2013–2014

Teen childbearing can have negative health, economic, and social consequences for mothers and their children (1) and costs the United States approximately

HIV Prevention Among African American Youth: How Well Have Evidence-Based Interventions Addressed Key Theoretical Constructs?

9.4 billion annually (2). During 1991-2014, the birth rate among teens aged 15-19 years in the United States declined 61%, from 61.8 to 24.2 births per 1,000, the lowest rate ever recorded (3). Nonetheless, in 2014, the teen birth rate remained approximately twice as high for Hispanic and non-Hispanic black (black) teens compared with non-Hispanic white (white) teens (3), and geographic and socioeconomic disparities remain (3,4), irrespective of race/ethnicity. Social determinants associated with teen childbearing (e.g., low parental educational attainment and limited opportunities for education and employment) are more common in communities with higher proportions of racial and ethnic minorities (4), contributing to the challenge of further reducing disparities in teen births. To examine trends in births for teens aged 15-19 years by race/ethnicity and geography, CDC analyzed National Vital Statistics System (NVSS) data at the national (2006-2014), state (2006-2007 and 2013-2014), and county (2013-2014) levels. To describe socioeconomic indicators previously associated with teen births, CDC analyzed data from the American Community Survey (ACS) (2010-2014). Nationally, from 2006 to 2014, the teen birth rate declined 41% overall with the largest decline occurring among Hispanics (51%), followed by blacks (44%), and whites (35%). The birth rate ratio for Hispanic teens and black teens compared with white teens declined from 2.9 to 2.2 and from 2.3 to 2.0, respectively. From 2006-2007 to 2013-2014, significant declines in teen birth rates and birth rate ratios were noted nationally and in many states. At the county level, teen birth rates for 2013-2014 ranged from 3.1 to 119.0 per 1,000 females aged 15-19 years; ACS data indicated unemployment was higher, and education attainment and family income were lower in counties with higher teen birth rates. State and county data can be used to understand disparities in teen births and implement community-level interventions that address the social and structural conditions associated with high teen birth rates.

Contraceptive Use Among Nonpregnant and Postpartum Women at Risk for Unintended Pregnancy, and Female High School Students, in the Context of Zika Preparedness — United States, 2011–2013 and 2015

Certain constructs are demonstrated in the research literature to be related to HIV risk behaviors among African American adolescents. This study examines how well these constructs are addressed in evidence-based interventions (EBIs) developed for this population. A literature review on variables for sexual risk behaviors among African American adolescents was undertaken. Simultaneously, a review was conducted of the contents of HIV-prevention EBIs. To facilitate comparison, findings from both were organized into constructs from prominent behavior change theories. Analysis showed that environmental conditions and perceived norms were frequently associated with sexual risk behaviors in the literature, while EBIs devoted considerable time to knowledge, skills, and self-efficacy. Findings imply that (a) EBIs might be complemented with activities that focus on important constructs identified in the literature and (b) researchers should better assess the relationship between skill development and HIV risk behaviors. Implications for practice and research are discussed.

Teen Pregnancy Prevention: Implementation of a Multicomponent, Community-Wide Approach

Zika virus infection during pregnancy can cause congenital microcephaly and brain abnormalities (1,2). Since 2015, Zika virus has been spreading through much of the World Health Organizations Region of the Americas, including U.S. territories. Zika virus is spread through the bite of Aedes aegypti or Aedes albopictus mosquitoes, by sex with an infected partner, or from a pregnant woman to her fetus during pregnancy.* CDC estimates that 41 states are in the potential range of Aedes aegypti or Aedes albopictus mosquitoes (3), and on July 29, 2016, the Florida Department of Health identified an area in one neighborhood of Miami where Zika virus infections in multiple persons are being spread by bites of local mosquitoes. These are the first known cases of local mosquito-borne Zika virus transmission in the continental United States.(†) CDC prevention efforts include mosquito surveillance and control, targeted education about Zika virus and condom use to prevent sexual transmission, and guidance for providers on contraceptive counseling to reduce unintended pregnancy. To estimate the prevalence of contraceptive use among nonpregnant and postpartum women at risk for unintended pregnancy and sexually active female high school students living in the 41 states where mosquito-borne transmission might be possible, CDC used 2011-2013 and 2015 survey data from four state-based surveillance systems: the Behavioral Risk Factor Surveillance System (BRFSS, 2011-2013), which surveys adult women; the Pregnancy Risk Assessment Monitoring System (PRAMS, 2013) and the Maternal and Infant Health Assessment (MIHA, 2013), which surveys women with a recent live birth; and the Youth Risk Behavior Survey (YRBS, 2015), which surveys students in grades 9-12. CDC defines an unintended pregnancy as one that is either unwanted (i.e., the pregnancy occurred when no children, or no more children, were desired) or mistimed (i.e., the pregnancy occurred earlier than desired). The proportion of women at risk for unintended pregnancy who used a highly effective reversible method, known as long-acting reversible contraception (LARC), ranged from 5.5% to 18.9% for BRFSS-surveyed women and 6.9% to 30.5% for PRAMS/MIHA-surveyed women. The proportion of women not using any contraception ranged from 12.3% to 34.3% (BRFSS) and from 3.5% to 15.3% (PRAMS/MIHA). YRBS data indicated that among sexually active female high school students, use of LARC at last intercourse ranged from 1.7% to 8.4%, and use of no contraception ranged from 7.3% to 22.8%. In the context of Zika preparedness, the full range of contraceptive methods approved by the Food and Drug Administration (FDA), including LARC, should be readily available and accessible for women who want to avoid or delay pregnancy. Given low rates of LARC use, states can implement strategies to remove barriers to the access and availability of LARC including high device costs, limited provider reimbursement, lack of training for providers serving women and adolescents on insertion and removal of LARC, provider lack of knowledge and misperceptions about LARC, limited availability of youth-friendly services that address adolescent confidentiality concerns, inadequate client-centered counseling, and low consumer awareness of the range of contraceptive methods available.

Cost-effectiveness of increasing access to contraception during the Zika virus outbreak, Puerto Rico, 2016

This article provides an overview and description of implementation activities of the multicomponent, community-wide initiatives of the Teenage Pregnancy Prevention Program initiated in 2010 by the Office of Adolescent Health and the Centers for Disease Control and Prevention. The community-wide initiatives applied the Interactive Systems Framework for dissemination and implementation through training and technical assistance on the key elements of the initiative: implementation of evidence-based teen pregnancy prevention (TPP) interventions; enhancing quality of and access to youth-friendly reproductive health services; educating stakeholders about TPP; working with youth in communities most at risk of teen pregnancy; and mobilizing the community to garner support. Of nearly 12,000 hours of training and technical assistance provided, the majority was for selecting, implementing, and evaluating an evidence-based TPP program. Real-world implementation of a community-wide approach to TPP takes time and effort. This report describes implementation within each of the components and shares lessons learned during planning and implementation phases of the initiative.

Efforts to Increase Implementation of Evidence-Based Clinical Practices to Improve Adolescent-Friendly Reproductive Health Services

We modeled the potential cost-effectiveness of increasing access to contraception in Puerto Rico during a Zika virus outbreak. The intervention is projected to cost an additional

Practical Approaches to Evaluating Progress and Outcomes in Community-Wide Teen Pregnancy Prevention Initiatives

33.5 million in family planning services and is likely to be cost-saving for the healthcare system overall. It could reduce Zika virus–related costs by

The Zika Contraception Access Network: a feasibility programme to increase access to contraception in Puerto Rico during the 2016–17 Zika virus outbreak

65.2 million (