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Compendium of Evidence-Based Interventions and
Best Practices for HIV Prevention

Personalized Cognitive Risk-Reduction Counseling (with optional sex diary)


Intervention Description

Target Population

Men who have sex with men (MSM) who are HIV seronegative and have undergone repeat HIV testing

Goal of Intervention
Reduce high-risk sexual behavior (i.e., unprotected anal sex with non-primary partners of unknown or discordant HIV status)

Brief Description

The Personalized Cognitive Risk-Reduction Counseling intervention (previously referred to as Self-Justifications Counseling) involves a single counseling session delivered to clients during the 1- to 2-week period between standard “pre-test” (risk-assessment) and “post-test” (results disclosure) HIV counseling. During the session, counselors ask the client to recall a recent encounter of unprotected anal sex with another man of unknown or serodiscordant HIV status. The client describes the encounter with as much detail as possible. The client is then encouraged to identify and express the thoughts, feelings, or attitudes that might have led to the high-risk behavior. Together, the client and the counselor examine the encounter to identify any thoughts that may have led the client to make a decision to engage in high transmission risk sex. Finally, the client and the counselor agree on strategies that can be used to deal with similar situations in the future.

An optional sex diary can be used to supplement the single counseling session. The diary asks clients to keep track of and describe all sex encounters for 90–days. The sex encounters include type of sex act (e.g., anal sex or oral sex), whether a condom was used, relationship to sex partners, and HIV serostatus of sex partners.

Theoretic Basis

  • Gold’s model of “on-line” vs. “off-line” self-appraisal of risk behavior
  • Model of Relapse Prevention

Intervention Duration
1 session that lasts approximately 1 hour

Intervention Setting
HIV testing clinic

Counselor, a licensed mental health professional

Delivery Methods
  • Counseling
  • Goal setting

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Intervention Package Information

An intervention package was developed with funding from CDC’s Replicating Effective Programs (REP) Project. The intervention package and training are available through CDC’s High Impact Prevention Project (HIP): Personalized Cognitive Counseling (PCC).

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Evaluation Study and Results

The original evaluation was conducted in San Francisco, California, between 1997 and 2000. The sample included 248 men who have sex with men (MSM) of negative or unknown HIV serostatus.

Key Intervention Effects
Reduced unprotected anal sex

Study Sample

  • 74% White, 11% Hispanic, 6% Asian/Pacific Islander, 3% African American, 6% other
  • 100% Male
  • Median age of 33 years

Recruitment Settings
Anonymous HIV testing clinic.

Eligibility Criteria
Men between the ages of 18 and 49 years, having at least one HIV-negative test result during the prior 6 months, and engaged in at least one episode of receptive/insertive unprotected anal sex with a man of unknown or discordant HIV status during the prior 12 months

Assignment Method
Men were randomly assigned to one of four groups: standard HIV counseling control (n = 62), standard HIV counseling + sex diary (n = 62), standard HIV counseling + risk-reduction counseling (n = 62), and standard HIV counseling + risk-reduction counseling + sex diary (n = 62).

Comparison Group
Standard HIV pre- and post-test counseling that followed CDC guidelines and was delivered by a licensed counselor. The counseling assessed reasons for testing, current HIV status, testing history, risk factors, proposed areas for behavior change, and means to stay safe until receipt of test results.

Relevant Outcomes Measured and Follow-up Time
Episodes (mean number and percent) of unprotected anal sex with any non-primary partner of unknown or discordant HIV status during the prior 3 months were assessed 6- and 12-months post-intervention.

Participant Retention

  • Standard + Personalized + Diary:
    79% retained at 6 months
    71% retained at 12 months
  • Standard + Personalized:
    94% retained at 6 months
    82% retained at 12 months
  • Standard + Diary:
    94% retained at 6 months
    84% retained at 12 months
  • Standard Only:
    92% retained at 4 months
    84% retained at 12 months

Significant Findings
At 6- and 12-month follow-ups, men receiving the Standard + Personalized Cognitive Risk-Reduction Counseling intervention had a significant decrease in percent (p < 0.002 and p = 0.001, respectively) and in mean number of episodes (p < 0.008 and p < 0.001, respectively) of unprotected anal sex compared to those receiving standard HIV counseling alone.

The addition of the diary to the Standard + Personalized Cognitive Risk-Reduction Counseling intervention also produced significant positive results, but did not produce results significantly better than those produced by the Standard + Personalized Cognitive Risk-Reduction Counseling intervention. Thus, the inclusion of the sex diary is optional.

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References and Contact Information

  • Dilley, J. W., Woods, W. J., Sabatino, J., Lihatsh, T., Adler, B., Casey, S., Rinaldi, J., Brand, R., & McFarland, W. (2002). Changing sexual behavior among gay male repeat testers for HIV: a randomized, controlled trial of a single-session intervention. Journal of Acquired Immune Deficiency Syndromes, 30, 177–186.

Researcher: Dr. James W. Dilley
Executive Director, AIDS Health Project
Box 0884, 1855 Folsom Street, MCB AHP
University of California, San Francisco
San Francisco, CA. 94143 – 0884

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  • Page last reviewed: November 25, 2015
  • Page last updated: November 25, 2015 The U.S. Government's Official Web PortalDepartment of Health and Human Services
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