Trial of an Adapted STD Screening and Risk Reduction Intervention

STDs including Neisseria gonorrhea, Chlamydia trachomatis and Trichomonas vaginalis, are an
urgent problem in American Indian/Alaska Native (AI/AN) communities due to a constellation of
risk and contextual factors affecting tribal populations. Geographic isolation and cultural
and social stigmatization contribute to poor access to screening, counseling and education,
and diminished opportunities for early identification of STDs. Evidence-based prevention, STD
screening and early identification are the best public health strategies to address a
potential epidemic among AI/ANs. However, there is currently a paucity of such strategies
that have been demonstrated in AI/AN populations. An intervention targeting STD screening and
related risk reduction behaviors has the potential to circumvent the continuous transference
of disease.

Participating Community: The Fort Apache Reservation is home to ~17,000 White Mountain Apache
tribal members, with almost half <20 years of age. The reservation encompasses 1.7 million
acres along northeastern Arizona. The Tribe endures notable demographic and environmental
challenges that impact behavioral risks among community members: 61% of the population >16
years old are either "Not in Labor Force" or unemployed. 47% of Apaches aged ≥25 have not
received a high school diploma. The median household income is $26,973 and 47% of the
population lives below the federal poverty line. Over half (53%)(1) of all Apache households
are led by single mothers;(2) 75% of children are born to unwed mothers.(3) These factors
contribute to high rates of school drop-out, substance use, high-risk sexual behavior and
poor mental and emotional health in the void of effective interventions. Despite these
challenges, the Apache community has successfully demonstrated the ability to adapt and
implement effective paraprofessional-administered interventions.(4,5)

Epidemiology of STD and Related Risk Behaviors: Recently, STD rates have increased throughout
Arizona, and the state's AI population bears a disproportionately high burden of new
infections.(6) In 2011, the chlamydia rate among AIs in Arizona was 6 times the rate for
non-Hispanic Whites.(6) The rate of gonorrhea among AIs in Arizona tripled between 2009 and
2011, a rise largely attributed to "outbreaks in tribal areas in the northeastern quadrant of
Arizona."(6) In 2011-2012, the chlamydia rate among Apaches was 2,116/100,000 for all ages,
nearly 5 times both Arizona and national all-ages rates. The Apache gonorrhea rate was
749/100,000 for all ages in 2011-2012, approximately 7 and 10 times higher than national and
Arizona all-ages rates, respectively. Previous studies indicate that among all races and
ethnicities AI/ANs have some of the highest rates of inconsistent condom use, multiple sex
partners and early sexual initiation.(7-10) The intersection of several behavioral risks such
as poor mental health, drug use and binge alcohol use has shown to increase STD risk
behaviors. A study conducted with Apache teens with recent suicidal behavior revealed high
rates of lifetime drug use: 92% for alcohol, 88% for marijuana, 38% for crack/cocaine, and
35% for methamphetamines, which is 3 times that of all AI/AN adolescents in 2009.
Highlighting the intersection of risk, 48% of those that were sexually active had ever used
cocaine compared with 17% of those not sexually active; similarly, 40% of sexually active
participants had ever used methamphetamine compared with 17% of participants that were not
sexually active.

There have been scarce rigorous RCTs of behavioral health interventions among AI populations
and none that have analyzed an EBI promoting STD screening or addressing the interrelated
risks of substance use, poor emotional health and STDs/ HIV/AIDS. This study targets the
shared root causes of substance use and sexual risk behaviors and aims to develop
personalized, strengths-based risk reduction strategies tailored to participants' and the
community's specific risk profiles.

Inclusion Criteria:

- Self-identified adults of American Indian ethnicity, who are members of the White
Mountain Apache community

- Ages 18 to 49;

- Written informed consent to participate in the study;

- Currently sexually active;

- At least one episode of binge substance use or suicidal ideation recorded in the
Apache community-based surveillance system in the past 90 days;

- Participant must agree to be audio recorded during intervention sessions

Exclusion Criteria:

- Inability to participate in full intervention (e.g., planned move, residential
treatment, etc.)

- Severe risk for suicide (i.e., suicide attempt within past 6 months) or

- Unwilling to be randomized