Gender-Specific HIV Prevention with Urban Early-Adolescent Girls: Outcomes of the Keeping' It Safe Program

Published in AIDS Education and Prevention (Vol. 19, No. 6, pages 479-488), this study evaluates the efficacy of Keepin' It Safe, a theory-based, gender-specific, CD-ROM-mediated HIV prevention programme for urban, early adolescent girls in the United States. The programme is based on the AIDS risk reduction model (ARRM), a 3-stage model of harm reduction that integrates concepts from the health belief model, the theory of reasoned action, the theory of planned behaviour, self-efficacy theory, emotional influences, and interpersonal processes. According to the ARRM, to avoid HIV infection, individuals engaging in sexual risk behaviours must perceive their actions as problematic (the so-called "labelling" stage), commit to changing the behaviours (the "commitment" stage), and take action to do so (the "action" stage).

Keepin' It Safe targets ARRM variables hypothesised to influence goal attainment at each stage. The first 2 sessions aim to increase HIV/AIDS knowledge and perceived vulnerability to HIV infection, factors that increase the ability to recognise and label risky sexual behaviours as problematic. The second and third sessions address the following key determinants of the commitment to changing high-risk behaviours: the perceived enjoyment of low-risk activities, the perceived efficacy of these activities in achieving risk reduction, and self-efficacy for low-risk activities. The final 2 sessions aim to increase sexual communication and assertiveness skills for enacting low-risk behaviours, and promote norms favouring partner involvement in low-risk activities.

Multiple media (i.e., digital video, graphics, animation, sound, and text) are used to interactively deliver programme content. Girls are provided with opportunities to apply their learning through participation in games, interactive assessments, and such skills-building exercises as: developing assertive responses for refusing requests to engage in risk-related sexual behaviours; identifying personal barriers to practicing abstinence and safer sex and developing strategies to overcome the barriers; placing cards listing the steps for using safer sex methods in the correct order; and developing, printing, and signing a behavioural contract indicating the commitment to practice abstinence or consistently use safer sex methods.

The study was conducted in youth services agencies located in the greater New York City area. Thirty-one youth services agency sites were randomised to computer intervention and control groups. Across sites, 204 girls between the ages of 11 and 14 years were administered pretests. Two weeks after pretesting, girls at computer intervention sites completed Keepin' It Safe in six onsite weekly sessions. Post-testing occurred 2 weeks after intervention or, for control group girls, 10 weeks after pretesting. Changes in HIV/AIDS knowledge, protective attitudes, and skills for reducing HIV risk-related sexual behaviours were tested using linear regression models that were controlled for baseline values of each outcome.

Girls exposed to Keepin' It Safe, relative to control group girls, increased their HIV/AIDS knowledge, perceived efficacy and enjoyment of abstinence, perceived efficacy and enjoyment of condoms, and sexual assertiveness. The finding that intervention-arm girls' perceived vulnerability to HIV actually decreased from pretest to post-test may be explained, the researchers speculate, by the fact that the girls were sexually inexperienced. "Possibly, girls' perceived vulnerability to infection decreased following intervention because they were more knowledgeable of the processes involved in the acquisition and transmission of HIV and therefore better able to assess their actual risk."

The researchers highlight the fact that Keepin' It Safe focuses on young girls, whereas prior gender-specific HIV prevention outcome studies have engaged older samples of sexually active girls. As young girls exposed to Keepin' It Safe mature and begin to experiment sexually, they can draw on the knowledge, protective attitudes, and skills for reducing HIV risk-related sexual behaviours. Further, they note that interactive approaches to gender-specific HIV prevention programming for adolescent girls are less common than traditional leader-delivered approaches. Compared to similar programmes that draw on a portable and cost effective delivery modality (e.g., CD-ROM), an advantage of Keepin' It Safe is the greater degree of active user involvement it requires.

In short: "Theory based, gender-specific HIV prevention programs are an essential component of the widespread effort to curtail the disproportionate impact of the HIV/AIDS epidemic on this population."