title: Sexual health risk reduction interventions for people with severe mental illness: a systematic review.
abstract: BACKGROUND
  Despite variability in sexual activity among people with severe mental illness, high-risk sexual behavior (e.g. unprotected intercourse, multiple partners, sex trade and illicit drug use) is common. Sexual health risk reduction interventions (such as educational and behavioral interventions, motivational exercises, counselling and service delivery), developed and implemented for people with severe mental illness, may improve participants' knowledge, attitudes, beliefs behaviors or practices (including assertiveness skills) and could lead to a reduction in risky sexual behavior. This systematic review evaluates the effectiveness of sexual health risk reduction interventions for people with severe mental illness.
  
  
  METHODS
  Thirteen electronic databases (including MEDLINE, EMBASE and PsycINFO) were searched to August 2014, and supplemented by hand-searching relevant articles and contacting experts. All controlled trials (randomized or non-randomized) comparing the effectiveness of sexual health risk reduction interventions with usual care for individuals living in the community with severe mental illness were included. Outcomes included a range of biological, behavioral and proxy endpoints. Narrative synthesis was used to combine the evidence.
  
  
  RESULTS
  Thirteen controlled trials (all from the USA) were included. Although there was no clear and consistent evidence that interventions reduce the total number of sex partners or improved behavioral intentions in sexual risk behavior, positive effects were generally observed in condom use, condom protected intercourse and on measures of HIV knowledge, attitudes to condom use and sexual behaviors and practices. However, the robustness of these findings is low due to the large between study variability, small sample sizes and low-to-moderate quality of included studies.
  
  
  CONCLUSIONS
  There is insufficient evidence at present to fully support or reject the identified sexual health risk reduction interventions for people with severe mental illness. Given the serious consequences of high-risk sexual behaviors, there is an urgent need for well-designed UK based trials, as well as training and support for staff implementing sexual health risk reduction interventions.
  
  
  BACKGROUND
  PROSPERO CRD42013003674 .
authors.affiliation: Health Economics and Decision Science, ScHARR, University of Sheffield, Sheffield, UK. a.pandor@sheffield.ac.uk.
authors.forename: Abdullah
authors.initials: A
authors.lastname: Pandor
authors.affiliation: Health Economics and Decision Science, ScHARR, University of Sheffield, Sheffield, UK. e.kaltenthaler@sheffield.ac.uk.
authors.forename: Eva
authors.initials: E
authors.lastname: Kaltenthaler
authors.affiliation: School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland. ahiggins@tcd.ie.
authors.forename: Agnes
authors.initials: A
authors.lastname: Higgins
authors.affiliation: School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK. Karen.Lorimer@gcu.ac.uk.
authors.forename: Karen
authors.initials: K
authors.lastname: Lorimer
authors.affiliation: Institute of Psychiatry at Kings College London, London, UK. shubulade.smith@kcl.ac.uk.
authors.forename: Shubulade
authors.initials: S
authors.lastname: Smith
authors.affiliation: Porterbrook Clinic, Sheffield, UK. k.r.wylie@sheffield.ac.uk.
authors.forename: Kevan
authors.initials: K
authors.lastname: Wylie
authors.affiliation: Health Economics and Decision Science, ScHARR, University of Sheffield, Sheffield, UK. ruth.wong@sheffield.ac.uk.
authors.forename: Ruth
authors.initials: R
authors.lastname: Wong
mesh_terms: D001521:Behavior Therapy; D005260:Female; D006801:Humans; D008297:Male; D001523:Mental Disorders; D060728:Reproductive Health; D040242:Risk Reduction Behavior; D012309:Risk-Taking; D012720:Severity of Illness Index; D012725:Sexual Behavior; D047568:Unsafe Sex / Q000517:prevention & control*