This application is responsive to the fourth research topic in Request for Applications RFA-PS-11-003, "A Sexual Health Approach for Black and Hispanic Youth: New strategies for prevention, screening and facilitating healthy choices." In Philadelphia, PA, urban Black adolescents are disproportionately impacted by unintended sexual outcomes, such as HIV, sexually transmitted infections (STIs) and unwanted pregnancies. Novel studies translated into nontraditional community programs to address overall sexual health and decrease sexual infections are essential for this population. The proposed study is an effort to translate the Principal Investigator's (PI's) preliminary research findings to benefit sexual health education needs identified within the local adolescent mental health community. The PI innovatively proposes the first steps in a program of research to address HIV/STI prevention needs in a historically underserved sector of the Black community- Black adolescents suffering from mental illnesses. The applicant is a young African American nurse scientist with a proven track record to implement culturally and linguistically competent research methodology, a history of service to Black communities, strong linkages to the targeted population and outstanding research training through the Center for Health Equity Research at the University of Pennsylvania School of Nursing. Accordingly, a community-based participatory research (CBPR) framework is proposed with mentorship by renowned senior scientists, Drs. Loretta Jemmott and Gina Wingood. Hard to reach, disenfranchised adolescents are at the epicenter of our national HIV/STI epidemic, and those with mental health illnesses are at heightened risk. Early sexual debut, substance abuse, poverty and limited educational attainment are all documented risk factors. Black adolescents with mental illnesses are at increased risk for HIV/STIs because they are more likely to encounter social and structural drivers of the HIV/STI epidemic. Further, research indicates that they engage in HIV/STI risk related sexual behaviors at higher rates than other adolescents. The delivery of HIV/STI prevention programming in a nontraditional setting, such as an outpatient mental health treatment program, may prove effective to engage at-risk Black adolescents with mental illnesses. Behavioral interventions have demonstrated efficacy in the general adolescent population;however, it remains unknown whether these findings translate to adolescents with mental illnesses. To enhance efficacy, interventions for this population should be targeted to account for unique social and psychological factors which may impair their ability to accurately appraise risky situations, control impulses and negotiate condom use. Despite these facts, a paucity of comprehensive evidence-based interventions are available to reduce HIV/STI risk among Black adolescents with mental illnesses. Through a health equity lens, and a social determinants approach to HIV/STI prevention, the purpose of this study is to develop and pilot a theoretically-driven, gender and culturally relevant, developmentally and psychologically appropriate behavioral intervention to reduce the risk of HIV/STIs among heterosexually-active Black adolescents (ages 13 to 17) with mental illnesses. A CBPR framework, the Theory of Planned Behavior, and the investigators'preliminary work with the target population will guide the research process. Both males and females (N= 128) currently receiving outpatient mental health treatment from a Philadelphia Community Behavioral Health (CBH) provider will be randomized to one of two conditions: 1) a targeted HIV/STI risk reduction intervention to reduce their risk of HIV and other STIs;or 2) an attention control condition on general health promotion to reduce their risk of adverse health conditions including cancer, obesity, and heart disease. In partnership with the community, the specific aims are focused on elucidation of factors that influence HIV/STI risk, intervention development, testing the intervention's effects on HIV/STI risk related sexual behavior and STI incidence, and testing the mediation of effects of the intervention. The primary study outcome is self-reported consistent condom use assessed at baseline, immediately post-intervention, and at 3-, 6- and 12-month follow-ups. Secondary outcomes include sexual activity, the number of concurrent and sequential sexual partners, the theoretical mediators of intervention effects (adolescents'attitudes, beliefs, intentions and self-efficacy) and laboratory confirmed STIs. These data will contribute to the development of evidence-based HIV/STI sexual risk reduction programs for Black adolescents with mental illnesses. Specifically, the intended impact is to: 1) generate data to address unique, unmet HIV/STI risk reduction needs via a gender and culturally relevant, developmentally and psychologically appropriate vehicle targeted to reach Black adolescents with mental illnesses;2) partner with community stakeholders to deliver a novel intervention in a nontraditional setting embedded in the community at risk to enhance sexual health dialogue and prevention efforts between adolescents and trusted adult facilitators;and 3) inform mental health policy toward the standardization of sexual health assessment and intervention in community outpatient mental health treatment. The investigator's long-term goal is to build an HIV epidemiologic prevention program of research focused on decreasing HIV/STI morbidity in highly affected urban Philadelphia, and generalizable to other urban communities. Given that adolescent health is imperative to public health, the proposed research is timely, innovative and bears great significance.
Heterosexually-active Black adolescents diagnosed with mental illnesses report increased rates of early sexual debut, noncondom use, and having sex with multiple sexual partners. Theory-based, gender and culturally relevant HIV/STI risk reduction interventions that focus on the psychopathology of mental illness are needed to improve sexual health within the target population. Delivery of HIV/STI prevention programming in outpatient mental health treatment, a nontraditional community-based setting, may reach adolescents who are not engaged in other settings (i.e. schools and churches).