Introduction to the Special Section on Families, Youth, and HIV: Family-Based Intervention Studies

Received November 27, 2005; revision received January 4, 2006; accepted January 9, 2006

Every year, a new generation at-risk for human immunodeficiency virus (HIV) and sexually transmitted infections (STIs) emerges, posing unique challenges for prevention and intervention. Young people are now at the center of the acquired immunodeficiency syndrome (AIDS) epidemic; 25% of STIs reported annually occur among youth, and around half of the people who acquire HIV become infected before they turn 25. AIDS is currently the leading cause of death in 15- to 24-year olds (National Center for Health Statistics, 2005). Most young people acquire HIV through unprotected sexual activity, and, thus, reducing adolescent sexual risk taking has become a national and international public health priority. Substance use also confers increased risk of exposure to HIV by impairing sexual decision-making and leading to inaccurate condom use. Unfortunately, rates of adolescent sexual behavior and substance use remain high. National surveys indicate that 60.7% of males and 62.3% of females report having had sexual intercourse by 12th grade, whereas only 67% of males and 48.5% of females report using a condom during their last sexual encounter (Grunbaum et al., 2004). Similarly, by 12th grade, males and females report high rates of alcohol (82.6 and 83.3%, respectively) and marijuana (51.7 and 44.9%, respectively) use, and notably 17.6% of females and 33.5% of males report using alcohol or drugs before last sexual intercourse (CDC, 2004). Reducing adolescent risky sexual and drug use behavior requires innovative solutions that are tailored to youths’ unique risk mechanisms. This special section describes four cutting edge prevention programs designed to reduce exposure to HIV/STIs among youth.

HIV and STI prevention programs for young people have changed over the course of the epidemic. At the beginning of the 1980s, the first generation of AIDS prevention programs designed for youth focused on increasing knowledge about HIV transmission and prevention. These efforts assumed that knowledge alone would produce necessary behavioral changes. Unfortunately, although these programs successfully increased accurate knowledge about the modes of transmission and strategies for prevention, they did not lead directly to behavior change (Coyle, Boruch, & Turner, 1991).

The second generation of HIV prevention programs sought to address these limitations by going beyond increasing knowledge. In the 1990s, HIV prevention interventions for youth drew on social cognitive theories to address perceptions of risk, safer-sex intentions, assertive communication, and condom use skills, in addition to HIV/STI knowledge. These programs yielded promising results, showing targeted reductions in sexual risk taking and other proximal factors, such as exposure to risk situations. Like HIV knowledge-based interventions, however, these programs focused on individual behavior, and few have produced long-term behavioral changes.

Family-Based HIV Prevention

Efforts to achieve more robust and durable effects have led to broader conceptualizations of adolescent risk behavior and change mechanisms. Recent theoretical formulations emphasize the role of families within the broad social context that shapes adolescent sexual socialization and development (Crosby & Miller, 2002; Fisher & Feldman, 1998; Perrino, Gonzalez-Soldevilla, Pantin, & Szapocznik, 2000). Although early research suggested that teens make a discrete break from their families, newer data indicate that adolescents negotiate an autonomy that allows them to incorporate values that are central to their parents. For example, the influence of this newer research is evident in the advertisements of Partnership for a Drug Free America. In fact, parents are teenagers’ primary sex educators, able to capitalize on teachable moments when youth may be more open to learning new information (Szapocznik & Coatsworth, 1999). Parents also function as resources for information and advice about partner selection and sexual decision-making. As a result, family members are in a unique position to teach youth responsible sexual behavior, and how to talk to partners about abstinence and safer sex. Risk-reduction programs can benefit from this natural opportunity for adolescent HIV prevention by teaching family members to deliver safer-sex messages. By intervening at the family level, parents can continue prevention messages after the formal program ends, thereby enhancing the likelihood of sustained behavioral changes (Pequegnat & Szapocznik, 2000).

Families influence adolescent sexual behavior in four primary ways (Donenberg & Pao, 2005), and these are often targeted in family-focused HIV prevention programs: (a) instrumental characteristics (parental monitoring, control); (b) affective parenting behavior (warmth, support); (c) parental attitudes about sex; and (d) parent–teen communication.

Instrumental Characteristics

Greater parental monitoring and less parental permissiveness are consistently related to later sexual initiation, less frequent sexual intercourse, less risky sexual behavior, fewer sexual partners, less pregnancy, and increased condom use among teens (Li, Feigelman, & Stanton, 2000; Miller, Forehand, & Kotchick, 1999; Romer et al., 1994). Parental monitoring reduces teenagers’ opportunities for sexual behavior (Paikoff, 1995) and is associated with reductions in other high-risk behaviors that often co-occur with risky sex, such as drug and alcohol use (Li et al., 2000; Thomas, Reifman, Barnes, & Farrell, 2000) and delinquency (Gorman-Smith, Tolan, Zelli, & Huesmann, 1996).

Affective Parenting Behavior

The emotional climate of the family significantly affects teens’ sexual risk behavior. Perceived parental warmth and support consistently predicts less adolescent risk taking. Close family relationships, parental support, low parental hostile control, and parent–teen relationship satisfaction, are associated with later sexual initiation and increased condom use (Chewning & Koningsveld, 1998; Donenberg, Bryant, Emerson, Wilson, & Pasch, 2003; Jaccard, Dittus, & Gordon, 1998). Similarly, family availability, support, connectedness, and cohesion are related to reduced sexual experience, less risky sexual behavior, and fewer health-risk behaviors (Borawski, Levers-Landis, Lovegreen, & Trapl, 2003; McBride, Paikoff, & Holmbeck, 2003; Miller, Benson, & Galbraith, 2001).

Parental Attitudes About Sex

Family attitudes serve as behavioral norms for children, who, through observation and modeling, learn how to behave in close relationships and to adopt positive approaches to health promotion (Jaccard & Dittus, 2000; Wickrama, Conger, Wallace, & Elder, 1999). Permissive parental attitudes about adolescent sexual behavior are related to teens’ sexual debut, sexual activity, and contraceptive use (Resnick et al., 1997). Likewise, if parents express stigmatizing attitudes toward persons with HIV disease, youth are more likely to adopt this stance.

Parent–Teen Communication

Evidence also underscores the importance of parent–child communication about sexual topics and safer-sex behavior (DiIorio, Pluhar, & Belcher, 2003; Jaccard & Dittus, 2000). Frequent parent–teen communication about sex-related topics has been associated with more responsible sexual behavior, less sexual experience, and increased contraceptive use among youth (Crosby et al., 2001; DiIorio et al., 2003). However, the quality of parent–teen communication may be more important than the frequency. Parent–adolescent communication that is open, receptive, and comfortable is related to less sexual experience and less risky sexual behavior among adolescents (Dutra, Miller, & Forehand, 1999; Miller, Norton, Fan, & Christopherson, 1998; Miller et al., 1999). Discussions with mothers about sex- and AIDS-related issues are associated with more consistent condom use when mothers are perceived as skilled, open, and comfortable during such discussions (Whitaker, Miller, May, & Levin, 1999).

Articles in the Special Section

This special section presents a snapshot of four first-generation family-based prevention programs designed to reduce child and adolescent risk for exposure to HIV/AIDS. Each program addresses at least one of the mechanisms believed to mitigate adolescent risk taking reviewed above. Each intervention emphasizes a unique approach to risk reduction, varying along multiple dimensions, including the underlying theoretical framework, targeted risk factors, the specific family members involved, and the outcomes measured. Despite these differences, the articles share some common threads. All of the authors adopted an inclusive definition of family, used culturally congruent methods, and capitalized on the resilience of families in designing the interventions. For example, each of the studies incorporates family members who are in an ongoing, parenting relationship with youth, to improve an aspect of the family process (parental monitoring, parental attitudes about HIV, parent–teen warmth, parent–adolescent communication). Similarly, each of the articles describes extensive strategies to recruit, and, in most cases, maintain over time, involvement of multiple family members in a preventive intervention. In addition, each of the studies grapples with theoretical issues regarding the roles of knowledge, attitudes, beliefs, and processes in HIV prevention, and decisions regarding the specific family factors to address.

Collectively, the articles present outcome data and the mechanisms responsible for behavior change. In the first article, Prado and colleagues discuss the challenges involved in recruiting and engaging Latino families in adolescent preventive research interventions. Prado et al. underscore the importance of approaching families within a cultural framework, and they discuss the obstacles to overcoming enrollment barriers.

The second article addresses issues of stigma related to being HIV positive. HIV-positive people are living longer, and they are facing new challenges with regard to stigma, prejudice, and social isolation. Likewise, family members of people with HIV must adapt to the medical and mental health needs of their relatives over the course of a chronic illness. Krauss and colleagues present data from a promising intervention designed to teach parents to be sex educators for their children and to change their children’s stigmatizing attitudes toward infected family members, friends, and neighbors.

Also in this special section, Baptiste and colleagues discuss the strengths and challenges of translating US-based HIV prevention programs for families and communities into international settings. Baptiste and colleagues describe two similar, yet unique, efforts to adapt the US CHAMP program into two different venues, South Africa and Trinidad/Tobago. Baptiste et al. stretch the definition of family to include the community, and they highlight the strengths and challenges in working collaboratively with the community to prevent HIV.

Finally, the fourth article underscores the important role that fathers can play in HIV prevention efforts. Most studies focus on mothers; yet, fathers clearly influence the fabric of sexual socialization. DiIorio et al. present evidence for social cognitive mediators of the relationship between father–son communication on boys’ high-risk behavior.

The Next Generation of Family-Based HIV Prevention Programs

The next generation of family-based HIV prevention programs will benefit from the lessons learned thus far, but they will also confront many challenges. First, future programs must determine how to achieve enduring and meaningful effects. Few studies follow youth and families over time, and, thus, it is not clear whether the positive initial behavioral changes are maintained. Early research suggests that booster or “refresher” sessions may enhance or sustain initial improvements, but it is not clear whether the changes can withstand significant developmental milestones (e.g., emerging adulthood). Second, it is now clear that family-based HIV prevention interventions reduce adolescent sexual risk behavior. Future research must determine the mediators, moderators, and mechanisms of treatment efficacy; that is, for whom, under what circumstances, with which family members, at what age, from which culture, the program is most effective. Clarifying the active ingredients of prevention programs will lead to more refined interventions.

The third challenge for family-based prevention research is understanding and addressing stigma. Stigma inhibits families from seeking prevention and treatment services, interferes with social support, and reduces the quality of life for those infected with HIV. Attending to the risk factors linked to stigma and its consequences will be essential to reach families who need primary and secondary prevention. A fourth challenge facing family prevention efforts is the time-intensive nature of working with multiple family members, addressing the needs of different targets in the program (parents and children), keeping family members engaged in the process, and recruiting and retaining family members to ensure external validity.

Finally, relatively little is understood about healthy sexual development and sexual practices among youth. Greater specificity and clarity in the range of adolescent sexual behavior will guide HIV prevention programs and assist parents in delivering safer-sex messages. Yet, research lacks a nuanced and meaningful definition of sexual risk taking. In most prevention studies, adolescents are divided into two distinct groups: sexually active and not (yet) sexually active. However, there is considerable variability within these categories with regard to the types of activities engaged in and frequency of those activities. For instance, youth may be categorized as sexually active based on a single experience. Thus, future research will necessitate a more careful examination and definition of adolescent sexual risk. Miller and colleagues (1997) offer one potential solution. Following face-to-face interviews with 907 dyads of adolescents and their mothers, the investigators propose five behavioral patterns of sexual behavior: (a) delayers (committed to abstinence), (b) anticipators (expecting to become sexually active in the next year), (c) one-timers (penile–vaginal intercourse only once), (d) steadies (in a sexually active relationship with one partner), and (e) multiples (have had penile–vaginal intercourse with more than one partner). Future research will determine the utility of this nomenclature.

In sum, the articles in this special section collectively have begun the process of addressing these important but not insurmountable challenges. To date, family-based HIV prevention for youth show highly promising effects. As additional long-term outcome data become available, we are hopeful that family involvement will lead to more robust positive adolescent behavioral changes.

Acknowledgments

The authors gratefully acknowledge the staff of the Healthy Youths Program for their assistance in preparing this manuscript. This research was supported by NIMH (R01MH58545; R01MH65155; R01MH63008; and R01MH068225). We thank our many collaborators who helped us in our work and the parents, caregivers, and youth, without whose involvement this research would not be possible.

References

Author notes

1University of Illinois at Chicago and 2National Institute of Mental Health