Abstinence-based programs for HIV infection prevention in high-income countries

A comprehensive review of reviews of school-based interventions to improve sexual-health

OBJECTIVE

To systematically review systematic reviews of school-based sexual-health and relationship Education (SHRE) programmes and, thereby, identify interventions and intervention components that promote reductions in risky sexual behaviour among young people.

METHODS

Electronic bibliographies were searched systematically to identify systematic reviews of school-based interventions targeting sexual-health. Results were summarised using a narrative synthesis.

RESULTS

Thirty-seven systematic reviews (summarising 224 primary randomised controlled trials) met our inclusion and quality assessment criteria. In general, these reviews analysed distinct sets of primary studies, and no comprehensive review of available primary studies was identified. Interventions were categorised into five types that segment this review literature. Unfortunately, many reviews reported weak and inconsistent evidence of behaviour change. Nonetheless, integration of review findings generated a list of 32 design, content and implementation characteristics that may enhance effectiveness of school-based, sexual-health interventions. Abstinence-only interventions were found to be ineffective in promoting positive changes in sexual behaviour. By contrast, comprehensive interventions, those specifically targeting HIV prevention, and school-based clinics were found to be effective in improving knowledge and changing attitudes, behaviours and health-relevant outcomes.

CONCLUSIONS

School-based interventions targeting risky sexual behaviour can be effective. Particular design, content and implementation characteristics appear to be associated with greater effectiveness. We recommend consideration of these characteristics by designers of school-based sexual-health interventions.

Abstinence-plus programs for HIV infection prevention in high-income countries

BACKGROUND

Abstinence-plus interventions promote sexual abstinence as the best means of preventing acquisition of HIV, but also encourage safer-sex strategies (eg condom use) for sexually active participants.

OBJECTIVES

To assess the effects of abstinence-plus programs for HIV prevention in high-income countries.

SEARCH STRATEGY

We searched 30 electronic databases (eg CENTRAL, PubMed, EMBASE, AIDSLINE, PsycINFO) ending February 2007. Cross-referencing, hand-searching, and contacting experts yielded additional citations.

SELECTION CRITERIA

We included randomized and quasi-randomized controlled trials evaluating abstinence-plus interventions in high-income countries (as defined by the World Bank). Interventions were any efforts that encouraged sexual abstinence as the best means of HIV prevention, but also promoted safer sex. Results were self-reported biological outcomes, behavioral outcomes, and HIV knowledge.

DATA COLLECTION AND ANALYSIS

Three reviewers independently appraised 20070 citations and 325 full-text papers for inclusion and methodological quality; 39 evaluations were included. Due to heterogeneity and data unavailability, we presented the results of individual studies instead of a meta-analysis.

MAIN RESULTS

Studies enrolled 37724 North American youth; participants were ethnically diverse. Programs took place in schools (10), community facilities (24), both schools and community facilities (2), healthcare facilities (2), and family homes (1). Median final follow-up occurred 12 months after baseline. Results showed no evidence that abstinence-plus programs can affect self-reported sexually transmitted infection (STI) incidence, and limited evidence that programs can reduce self-reported pregnancy incidence. Results for behavioral outcomes were promising; 23 of 39 evaluations found a significantly protective intervention effect for at least one behavioral outcome. Consistently favorable program effects were found for HIV knowledge.No adverse effects were observed. Several evaluations found that one version of an abstinence-plus program was more effective than another, suggesting that more research into intervention mechanisms is warranted. Methodological strengths included large samples and statistical controls for baseline values. Weaknesses included under-utilization of relevant outcomes, self-report bias, and analyses neglecting attrition and clustered randomization.

AUTHORS' CONCLUSIONS

Many abstinence-plus programs appear to reduce short-term and long-term HIV risk behavior among youth in high-income countries. Evidence for program effects on biological measures is limited. Evaluations consistently show no adverse program effects for any outcomes, including the incidence and frequency of sexual activity. Trials comparing abstinence-only, abstinence-plus, and safer-sex interventions are needed.