A variety of strategies can lead to sustained behavior changes that reduce the risk of STDs. These intervention strategies include individually focused interventions relying heavily on one-on-one counseling that occurs independent of, or jointly with, STD testing; group- or community-based interventions (Kelly, 1994); and structural or "macro" level legislative solutions. A review of federally funded HIV prevention studies that evaluated the impact of individual- and community-based behavioral interventions found that most interventions had positive effects on knowledge of AIDS and sexual behavior such as increased rates of condom use (IOM, 1994). The intent of STD preventive interventions is to reduce the incidence of new STDs by assisting individuals in changing behaviors in ways that decrease risk of contracting STDs. Altering precursors of sexual decision making and actual sexual practices, such as increasing rates of condom use, reducing number of partners, or decreasing rates of unprotected sex, will ultimately reduce the number of new cases of STDs.
While reduced STD incidence and sexual behavior change are the primary endpoints in STD risk-reduction interventions, other endpoints also have merit. For example, several important studies in STD prevention have utilized changes in risk behavior intentions, condom use attitudes, and perceived vulnerability as principal outcome measures. Community-level interventions based on "stages of change" theoretical models (Prochaska and DiClemente, 1983) have defined success on the basis of shifting community attitudes towards greater readiness to enact a specific behavior change, stronger change intentions, or future resolve to engage in protective behavior. "Social marketing" approaches to condom promotion have included condom sales in the community as an indicator of programmatic success. Success needs to be judged independently for specific target populations and for desired behavioral and disease outcomes.
Among adolescents, delaying sexual intercourse or intermittent avoidance of sexual activity is effective in STD risk reduction (Kirby, 1980). Furthermore, it has been well documented (Gold et al., 1994; Ku et al., 1994) that it is easier to encourage consistent condom use in sexual relationships with nonprimary partners than in primary relationships. Thus, the context of behavioral change strategies needs to be specified.
The literature on the effectiveness of HIV prevention programs contains some findings applicable for developing other effective STD prevention programs. Holtgrave and others (1995) found that successful prevention programs that were able to avert, reduce, or modify HIV-risk-related behaviors or their determinants had the following characteristics: