Sister to Sister: An HIV Risk Reduction Intervention

The Research

The Science behind the Package

Sister to Sister is a brief, individual-level skills-based safer sex intervention designed to improve women’s knowledge, beliefs and motivation, to change their behavior in ways that will reduce their risk for sexually transmitted infections (STDs), and HIV. It is also designed to increase self-efficacy and build skills to practice these behaviors.

Sister to Sister is based on the Social Cognitive Theory and uses a combination of exercises, videos, and practice techniques to deliver information and build skills that may reduce women’s risk for sexually transmitted diseases including HIV.

Target Population
Women, 18-45 years of age, attending family planning clinics and other reproductive health care clinics

Intervention
Sister to Sister is a one-on-one brief intervention, lasting about 20 to 30 minutes. The intervention package consists of a risk assessment interview guide, 4 educational posters, a facilitator teaching guide, participant’s guide, and 2 short, dramatic role-play video clips. The skills building activities include a condom demonstration, practice with an anatomically correct penis model, and role-playing. Other activities are designed to help women recognize that faulty reasoning and decision-making can increase their risk of HIV infection. The activities help women understand the adverse consequences of participating in unsafe sexual activity and the positive consequences of safer sexual practices, including abstinence. The women engage 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 learn to use condoms correctly. Two brief video clips evoke feelings, thoughts, attitudes, and beliefs about HIV/STD infection, AIDS, and sexual risk behavior while demonstrating prevention skills. The women also participate in role-playing scenarios that allow them to observe, analyze, and practice the skills of negotiating abstinence or condom use in a variety of circumstances.

Research Results
Women in both the one-on-one and small-group skill building interventions (combined) compared to the information intervention or health-control intervention participants reported:

• a greater proportion of condom use in the past three months,
• a greater proportion of using a condom the last time they had intercourse, and
• less unprotected sexual intercourse.

These results were statistically significant at the 3-month follow up and 12-month follow up. No differences were statistically significant at 6-month follow-up.

Women in the one-on-one skills-building intervention were less likely to test positive for a STD at the 12-month follow-up than the women in the control group.

For Details on the Research Findings
Jemmott LS, Jemmott JB, O’Leary A. Effects on Sexual Risk Behavior and STD rate of Brief HIV/STD Prevention Interventions for African American Women in Primary Settings. AJPH. 2007. 97 (6):1-7.

The Intervention

A Package Developed from Science
Replicating Effective Programs (REP) is a CDC-initiated project that supports the translation of evidence-based HIV/AIDS prevention interventions into everyday practice, by working with the original researchers in developing a user-friendly package of materials designed for prevention providers. Sister to Sister is one of the REP interventions and is the product of extensive collaboration among researchers, a community advisory board, and other community agencies. The package has been field tested in several community agencies and clinics across the United States by non-research staff.

Core Elements
Core elements are intervention components that must be maintained without alteration to ensure program effectiveness.

The core elements of Sister to Sister include:

Content Core Element

1: Address three outcome expectancies regarding condom use

• Prevention Outcome Expectancy (the perception that condoms prevent HIV/STDs)
• Sexual Pleasure Outcome Expectancy (reduce the perception that condoms interfere with sexual pleasure)
• Partner Reaction Outcome Expectancy (reduce the perception that their partner will hit them, leave them, or find another woman)

Content Core Element

2: Teach, demonstrate, and practice negotiation and refusal skills

• Teach negotiation, refusal and reframing skills using the 4-step SWAT Negotiation Strategy to respond to partner’s negative reaction towards condom use
• Practice negotiation, refusal, and reframing skills through role-play activities

Content Core Element

3: Condom use demonstration (2-step procedure)

• The health care provider teaches condom use skills by demonstrating how to use a condom on an anatomically correct penis model
• The patient practices the skill on the same model

Content Core Element

4: Build self-efficacy to empower the women to want to be safe sexually

• Incorporate the theme “Sister to Sister: Respect Yourself, Protect Yourself, Because You Are worth It” throughout the intervention
• Incorporate positive reinforcement, support and constructive feedback in all intervention activities, especially in the role-plays and condom demonstrations In addition, there are Implementation Core Elements that are integral to the intervention.

Implementation

Core Element

5: Demonstrate a caring attitude

• The facilitator must create a supportive and caring environment.
  • For example, there should be an “I truly care about you, I believe in you and you can do this” feeling throughout the intervention (i.e., active listening, eye contact, supportive feedback, be nonjudgmental, show respect, etc.).

Implementation Core Element

6: Integrate and use the core intervention materials

• Implementation Manual with a Facilitator Teaching Guide summarizing the dialogue between clinician and patient
• Participant’s Guide
• Anatomically correct penis model
• Video clips specifically selected for the intervention
• Personalized sexual risk assessment tool to initiate discussion

Implementation Core Element

7: Implemented by specially trained female health care staff that provides direct service to women (who attended the 8-hour training).

Package Contents

• Sister to Sister Implementation Manual including a Facilitator’s
  Teaching Guide containing the Facilitator’s script used to deliver the intervention to the participant
• Posters, video clips, informational pamphlet, Participant’s Guide
• CD of intervention materials for reproduction, such as the Participant’s Guide and informational pamphlet and a DVD containing video clips

Timeline for Availability
The package is available from CDC along with training on program implementation and technical assistance.

For More Information on the Sister to Sister Intervention Package
Loretta Sweet Jemmott, Ph.D, RN, FAAN, University of Pennsylvania School of Nursing, Center for Health Equity Research, 418 Curie Boulevard, 2L, 239 Philadelphia, PA 19104, 215-898-6373, jemmott@nursing.upenn.edu.

To find out more about future trainings, please visit Effective Interventions.