behavioral norms in the population. This strategy has been viewed as extremely successful in interventions focused on gay men. A second approach, "social marketing" (Andreasen, 1995), uses media campaigns to change attitudes towards condoms and improve their availability.
Intensive small-group risk-reduction interventions, largely guided by cognitive-behavioral theory, have been shown to be very effective in promoting self-protective behavior change (Kelly, 1994; Cleary et al., 1995). These studies have included randomized trials with gay men (Kelly et al., 1991), homeless and runaway adolescents (Rotheram-Borus et al., 1991), adolescents at risk for STDs (Jemmott et al., 1992; St. Lawrence et al., 1995), low-income and adult women of certain ethnic groups (Hobfoll et al., 1994; DiClemente and Wingood, 1995) and at-risk mentally ill men and women (Kalichman et al., 1994). These interventions have been delivered in small-group programs with 6 to 18 hours of contact time, allowing time to practice risk-reduction skills and review successes and problems encountered in enacting these behaviors. These interventions produced evidence of change in self-reported sexual risk behavior, usually on the order of 30 to 70 percent reduction in the frequency of unprotected sex from pre-intervention levels. While none of these studies incorporated STD incidence as a primary outcome measure, each study did utilize some method to validate self-reported behavioral changes. A limitation to these studies is that long-term maintenance of behavior change effects has not been examined.
Brief interventions focused on influencing knowledge and attitudes have been successful (Kalichman et al., 1994) but have had little impact on sexual behavior practices. Other strategies have focused on counseling and HIV testing as a method of increasing perceptions of vulnerability and promoting self-protection from STDs. Analyses of these strategies suggest that while these approaches have merit, the counseling, as practiced in field conditions, leaves much to be desired in meeting minimal criteria for being "successful" (Giesecke et al., 1991; Higgins et al., 1991).
Preliminary results of a major randomized, controlled trial evaluating the impact of enhanced prevention counseling for HIV and STD risk reduction strongly support individual-focused counseling (Kamb et al., 1996). Among public STD clinic patients, those who received a series of counseling sessions based on the Health Belief Model or the Theory of Reasoned Action were significantly more likely to adopt certain protective behaviors and less likely to acquire new STDs at six months of follow-up compared to those who received only educational messages.
In its latest report, the U.S. Preventive Services Task Force concluded that the ability of primary care clinicians to influence high-risk sexual behavior is limited, but that there is consistent evidence that Americans have changed their