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

Maternal Communication About Sexual Content and Ease of Access to Contraceptives

Previous literature has emphasized the role of mothers in sexual health communication with their adolescents. However, the extant literature lacks exploration of the importance of parental communication in association to specific risk-reduction behaviors, such as access to contraceptives. Therefore, the purpose of the current study was to explore the roles of parental attachment, the mother-daughter relationship, and communication about sexual content during adolescence in relation to women's recalled access to contraceptives during their teen years. Cisgender female participants aged between 18 and 35 (N = 582) were retrospectively assessed on maternal and paternal attachment, the mother-daughter relationship, mother-daughter communication about sexual content, and their own access to contraceptives during their teen years. After controlling for socioeconomic status, participant race, and history of pregnancy, only maternal communication about sexual content significantly related to access to contraceptives and ease of access to contraceptives. These results demonstrated that specific communication about sexual content was associated with greater access and ease of access to contraceptives, whereas more general relationship factors and communication did not.

Sexual health (excluding reproductive health, intimate partner violence and gender-based violence) and COVID-19: a scoping review

OBJECTIVES

The COVID-19 pandemic has exposed and exacerbated existing socioeconomic and health disparities, including disparities in sexual health and well-being. While there have been several reviews published on COVID-19 and population health disparities generally-including some with attention to HIV-none has focused on sexual health (ie, STI care, female sexual health, sexual behaviour). We have conducted a scoping review focused on sexual health (excluding reproductive health (RH), intimate partner violence (IPV) and gender-based violence (GBV)) in the COVID-19 era, examining sexual behaviours and sexual health outcomes.

METHODS

A scoping review, compiling both peer-reviewed and grey literature, focused on sexual health (excluding RH, IPV and GBV) and COVID-19 was conducted on 15 September 2020. Multiple bibliographical databases were searched. Study selection conformed to Joanna Briggs Institute (JBI) Reviewers' Manual 2015 Methodology for JBI Scoping Reviews. We only included English-language original studies.

RESULTS

We found that men who have sex with men may be moving back toward pre-pandemic levels of sexual activity, and that STI and HIV testing rates seem to have decreased. There was minimal focus on outcomes such as the economic impact on sexual health (excluding RH, IPV and GBV) and STI care, especially STI care of marginalised populations. In terms of population groups, there was limited focus on sex workers or on women, especially women's sexual behaviour and mental health. We noticed limited use of qualitative techniques. Very few studies were in low/middle-income countries (LMICs).

CONCLUSIONS

Sexual health research is critical during a global infectious disease pandemic and our review of studies suggested notable research gaps. Researchers can focus efforts on LMICs and under-researched topics within sexual health and explore the use of qualitative techniques and interventions where appropriate.

Education of Adolescents in the Prevention of HIV/AIDS in the Czech Republic

The number of HIV-positive people in the Czech Republic has trebled over the last decade. An educational programme aimed at the prevention of HIV and STDs in adolescents between 13 and 19 years of age is underway in the Moravian-Silesian Region in the Czech Republic. All schools in the region have been offered the chance to participate in the programme (on a voluntary basis). The programme consists of an educational lecture and a game with interactive elements; the students perform various tasks in groups. An anonymous paired questionnaire (input/output) was used to assess the efficacy of the programme. In order to evaluate the programme efficacy, descriptive statistics, non-parametric Wilcoxon paired test at the level of significance of 5%, and a model of logistic regression for a dichotomous variable were used. A total of 1210 students took part in the programme. The students’ knowledge improved, on average, by 15.5%. The highest efficacy was observed in the age group of 13–14-year-olds, where the improvement reached 17.9%. The educational programme was effective in raising awareness about STDs. Due to the observed increase in knowledge especially among the youngest participants (13–14 years old), we recommend aiming further interventions at the youngest age groups.

Effectiveness of School-Based Teen Pregnancy Prevention Programs in the USA: a Systematic Review and Meta-Analysis

School-based programs have been a mainstay of youth pregnancy prevention efforts in the USA. We conducted a systematic review and meta-analysis to assess their effectiveness. Eligible studies evaluated the effect on pregnancy rates of programs delivered in elementary, middle, or high schools in the USA and Canada, published between January 1985 and September 2016. The primary outcome was pregnancy; secondary outcomes were delay in sexual initiation, condom use, and oral contraception use. Randomized controlled trials (RCTs) and non-RCTs with comparator groups were eligible. We developed a comprehensive search strategy, applied to major bibliographic databases, article bibliographies, gray literature, and contact with authors. We calculated risk ratios (RR) with 95% confidence intervals (CI) for each outcome and pooled data in random effects meta-analysis. We used Grading of Recommendations Assessment, Development and Evaluation (GRADE) to assess evidence quality. Ten RCTs and 11 non-RCTs conducted from 1984 to 2016 yielded 30 unique pooled comparisons for pregnancy, of which 24 were not statistically significant. Six showed statistically significant changes in pregnancy rates: two with increased risk (RR 1.30, 95% CI 1.02-1.65; and RR 1.39, 95% CI 1.10-1.75) and four with decreased risk ranging from RR 0.56, 95% CI 0.41-0.77, to RR 0.75, 95% CI 0.58-0.96. All studies were at high risk of bias, and the quality of evidence was low or very low. Identified evidence indicated no consistent difference in rates of pregnancies between intervention recipients and controls.

State of HIV in the US Deep South

The Southern United States has been disproportionately affected by HIV diagnoses and mortality. To inform efforts to effectively address HIV in the South, this manuscript synthesizes recent data on HIV epidemiology, care financing, and current research literature on factors that predispose this region to experience a greater impact of HIV. The manuscript focuses on a specific Southern region, the Deep South, which has been particularly affected by HIV. Epidemiologic data from the Centers from Disease Control and Prevention indicate that the Deep South had the highest HIV diagnosis rate and the highest number of individuals diagnosed with HIV (18,087) in 2014. The percentage of new HIV diagnoses that were female has decreased over time (2008-2014) while increasing among minority MSM. The Deep South also had the highest death rates with HIV as an underlying cause of any US region in 2014. Despite higher diagnosis and death rates, the Deep South received less federal government and private foundation funding per person living with HIV than the US overall. Factors that have been identified as contributors to the disproportionate effects of HIV in the Deep South include pervasive HIV-related stigma, poverty, higher levels of sexually transmitted infections, racial inequality and bias, and laws that further HIV-related stigma and fear. Interventions that address and abate the contributors to the spread of HIV disease and the poorer HIV-related outcomes in the Deep South are warranted. Funding inequalities by region must also be examined and addressed to reduce the regional disparities in HIV incidence and mortality.

Interventions to reduce risk for sexually transmitted infections in adolescents: A meta-analysis of trials, 2008-2016

BACKGROUND

Numerous studies have evaluated the efficacy of interventions to reduce risk for sexually transmitted infections in adolescents in recent years, but their global effects remain unknown since 2008, the last date of a comprehensive review of prior studies.

AIMS

This study aims at evaluating the efficacy of interventions to promote sexual health, reduce STIs and unplanned pregnancies targeted to adolescents available after 2008; and analyzing the moderators of their global efficacy.

METHODS

We searched electronic databases and manual searches of some journals focused on STIs in May 2016. The studies evaluated the efficacy of interventions to reduce sexual risk in adolescents (age range: 11-19) anywhere in the world. Effect size of the relevant outcomes for sexual risk was calculated for every study. Analyses incorporated random-effect assumptions for each outcome. The homogeneity in the results was examined with the I2 statistic and its associated 95% confident interval.

RESULTS

Data from 63 studies (59,795 participants) were analyzed for behavioral and non-behavioral outcomes. In the short term, interventions had a positive impact in sexual health-related knowledge (Hedges'g = 1.01), attitudes (g = 0.29), self-efficacy toward condom use (g = 0.22), intention to refuse sex (g = 0.56), condom use intention (g = 0.46), and condom use (g = 0.38). In the medium term, positive effects observed at the short-term were maintained, although effect size significantly decreased in all variables. In the long term, interventions improved condom use (g = 0.47). Moderators of the efficacy are discussed.

CONCLUSIONS

Sexual health promotion interventions are effective to promote sexual health through increasing condom use. Effects on non-behavioral variables tend to decrease over time, while condom use increased in the long-term. Interventions should focus on the long-term efficacy, especially in behavioral and biological measures.

Abstinence-Only-Until-Marriage Policies and Programs: An Updated Position Paper of the Society for Adolescent Health and Medicine

Abstinence from sexual intercourse can be a healthy choice for adolescents, particularly if an adolescent is not ready to engage in sex. However, government programs exclusively promoting abstinence-only-until-marriage (AOUM) are problematic from scientific and ethical viewpoints. Most young people initiate sexual intercourse as adolescents or young adults, and given a rising age at first marriage around the globe, increasingly fewer adolescents wait until marriage to initiate sex. While theoretically fully protective, abstinence intentions often fail, as abstinence is not maintained. AOUM programs are not effective in delaying initiation of sexual intercourse or changing other behaviors. Conversely, many comprehensive sexuality education programs successfully delay initiation of sexual intercourse and reduce sexual risk behaviors. AOUM programs inherently provide incomplete information and are often neglectful to sexually active adolescents; lesbian, gay, bisexual, transgender, and questioning adolescents; pregnant and parenting adolescents; and survivors of sexual assault. Promotion of AOUM policies by the U.S. government has undermined sexuality education in the United States and in U.S. foreign aid programs to prevent HIV infection. In many U.S. communities, AOUM programs have replaced more comprehensive approaches to sexuality education.

Abstinence-Only-Until-Marriage Policies and Programs: An Updated Position Paper of the Society for Adolescent Health and Medicine

Abstinence from sexual intercourse can be a healthy choice for adolescents, particularly if an adolescent is not ready to engage in sex. However, government programs exclusively promoting abstinence-only-until-marriage (AOUM) are problematic from scientific and ethical viewpoints. Most young people initiate sexual intercourse as adolescents or young adults, and given a rising age at first marriage around the globe, increasingly fewer adolescents wait until marriage to initiate sex. While theoretically fully protective, abstinence intentions often fail, as abstinence is not maintained. AOUM programs are not effective in delaying initiation of sexual intercourse or changing other behaviors. Conversely, many comprehensive sexuality education programs successfully delay initiation of sexual intercourse and reduce sexual risk behaviors. AOUM programs inherently provide incomplete information and are often neglectful to sexually active adolescents; lesbian, gay, bisexual, transgender, and questioning adolescents; pregnant and parenting adolescents; and survivors of sexual assault. Promotion of AOUM policies by the U.S. government has undermined sexuality education in the United States and in U.S. foreign aid programs to prevent HIV infection. In many U.S. communities, AOUM programs have replaced more comprehensive approaches to sexuality education.

Effectiveness of a girls' empowerment programme on early childbearing, marriage and school dropout among adolescent girls in rural Zambia: study protocol for a cluster randomized trial

Background

Adolescent pregnancies pose a risk to the young mothers and their babies. In Zambia, 35% of young girls in rural areas have given birth by the age of 18 years. Pregnancy rates are particularly high among out-of-school girls. Poverty, low enrolment in secondary school, myths and community norms all contribute to early childbearing. This protocol describes a trial aiming to measure the effect on early childbearing rates in a rural Zambian context of (1) economic support to girls and their families, and (2) combining economic support with a community intervention to enhance knowledge about sexual and reproductive health and supportive community norms.

Methods/design

This cluster randomized controlled trial (CRCT) will have three arms. The clusters are rural schools with surrounding communities. Approximately 4900 girls in grade 7 in 2016 will be recruited from 157 schools in 12 districts. In one intervention arm, participating girls and their guardians will be offered cash transfers and payment of school fees. In the second intervention arm, there will be both economic support and a community intervention. The interventions will be implemented for approximately 2 years. The final survey will be 4.5 years after recruitment. The primary outcomes will be “incidence of births within 8 months of the end of the intervention period”, “incidence of births before girls’ 18th birthday” and “proportion of girls who sit for the grade 9 exam”. Final survey interviewers will be unaware of the intervention status of respondents. Analysis will be by intention-to-treat and adjusted for cluster design and confounders. Qualitative process evaluation will be conducted.

Discussion

This is the first CRCT to measure the effect of combining economic support with a community intervention to prevent adolescent childbearing in a low- or middle-income country. We have designed a programme that will be sustainable and feasible to scale up. The findings will be relevant for programmes for adolescent reproductive health in Zambia and similar contexts.

Trial registration

ISRCTN registry: ISRCTN12727868, (4 March 2016).

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1682-9) contains supplementary material, which is available to authorized users.

Correlates of HIV testing among African American and Latino church congregants: the role of HIV stigmatizing attitudes and discussions about HIV

Faith-based organizations can be key settings in which to reach African Americans and Latinos for HIV prevention, but little is known regarding factors that predict congregants' HIV testing behaviors. We examined the extent to which sociodemographic factors, HIV-related cues to action (e.g., knowing someone who is HIV-positive), and the social climate surrounding HIV (stigma toward a hypothetical HIV-positive congregant, HIV-related discussions at church about abstinence, condoms, and testing) were associated with willingness to be tested in church and with ever having been tested among 1211 African American and Latino congregants. Multivariate analyses indicated that congregants were more open to church-based testing if they were younger and had discussed condoms at church. They were less open if they expressed stigmatizing attitudes toward a hypothetical congregant. Foreign-born Latinos with low English proficiency were more willing to be tested at church than were African Americans. Congregants were more likely to have ever been tested if they were younger, African American, female, or married; if they knew someone who was HIV-positive; and if they had discussed testing and condoms at church. They were less likely if they had discussed abstinence. Open dialogue around HIV may activate congregants to be more receptive to church-based prevention.

Impact of community-based interventions on HIV knowledge, attitudes, and transmission

In 2012, an estimated 35.3 million people lived with HIV, while approximately two million new HIV infections were reported. Community-based interventions (CBIs) for the prevention and control of HIV allow increased access and ease availability of medical care to population at risk, or already infected with, HIV. This paper evaluates the impact of CBIs on HIV knowledge, attitudes, and transmission. We included 39 studies on educational activities, counseling sessions, home visits, mentoring, women's groups, peer leadership, and street outreach activities in community settings that aimed to increase awareness on HIV/AIDS risk factors and ensure treatment adherence. Our review findings suggest that CBIs to increase HIV awareness and risk reduction are effective in improving knowledge, attitudes, and practice outcomes as evidenced by the increased knowledge scores for HIV/AIDS (SMD: 0.66, 95% CI: 0.25, 1.07), protected sexual encounters (RR: 1.19, 95% CI: 1.13, 1.25), condom use (SMD: 0.96, 95% CI: 0.03, 1.58), and decreased frequency of sexual intercourse (RR: 0.76, 95% CI: 0.61, 0.96). Analysis shows that CBIs did not have any significant impact on scores for self-efficacy and communication. We found very limited evidence on community-based management for HIV infected population and prevention of mother- to-child transmission (MTCT) for HIV-infected pregnant women. Qualitative synthesis suggests that establishment of community support at the onset of HIV prevention programs leads to community acceptance and engagement. School-based delivery of HIV prevention education and contraceptive distribution have also been advocated as potential strategies to target high-risk youth group. Future studies should focus on evaluating the effectiveness of community delivery platforms for prevention of MTCT, and various emerging models of care to improve morbidity and mortality outcomes.

Reporting quality of search methods in systematic reviews of HIV behavioral interventions (2000-2010): are the searches clearly explained, systematic and reproducible?

Systematic reviews are an essential tool for researchers, prevention providers and policy makers who want to remain current with the evidence in the field. Systematic review must adhere to strict standards, as the results can provide a more objective appraisal of evidence for making scientific decisions than traditional narrative reviews. An integral component of a systematic review is the development and execution of a comprehensive systematic search to collect available and relevant information. A number of reporting guidelines have been developed to ensure quality publications of systematic reviews. These guidelines provide the essential elements to include in the review process and report in the final publication for complete transparency. We identified the common elements of reporting guidelines and examined the reporting quality of search methods in HIV behavioral intervention literature. Consistent with the findings from previous evaluations of reporting search methods of systematic reviews in other fields, our review shows a lack of full and transparent reporting within systematic reviews even though a plethora of guidelines exist. This review underscores the need for promoting the completeness of and adherence to transparent systematic search reporting within systematic reviews.

Nigerian secondary school adolescents’ perspective on abstinence-only sexual education as an effective tool for promotion of sexual health

The success of any type of sexual education programme depends on the knowledge and preparedness for practice by adolescents. A recent study has found that an ‘abstinence-only’ sexual education programme is effective in reducing sexual activity among adolescents. Knowledge of abstinence-only sexual education and preparedness for practice as an effective tool for promotion of sexual health among Nigerian secondary school adolescents was studied. An analytic descriptive survey design was used for the study. The research population comprised of all public secondary schools in three southern geopolitical zones of the Niger Delta Region of Nigeria. A multistage sampling technique was used to select 2020 senior secondary school (SS1-SS3) students as sample for the study. A partially self-designed and partially adapted questionnaire from an 'abstinence-only versus comprehensive sex education' debate, from debatepedia (http://wiki.idebate.org/), entitled 'Questionnaire on Nigerian Secondary School Adolescents’ Perspective on Abstinence-Only Sexual Education (QNSSAPAOSE)' was used in eliciting information from respondents. Hypotheses were formulated and tested. Frequency counts, percentage and Pearson Product Moment Correlation were used in analysing data. A greater proportion of secondary school adolescents in this study lacked knowledge of sexual education. About 80% of the respondents could not define sexual education. The general perspective on abstinence-only sexual education was negative, as revealed by the larger number of respondents who demonstrated unwillingness to practice abstinence-only sexual education. Specifically, of those who responded in favour of abstinence-only sexual education, the youngest group of adolescents (11-13 years) and the male respondents were more likely to accept this type of education than the other groups. Poor knowledge of sexual education could be responsible for unwillingness to practice abstinence-only sexual education. Sexual education should, therefore, be introduced into the secondary school curriculum and taught by well-prepared teachers to enable an informed decision on practice.

Combination prevention: new hope for stopping the epidemic

HIV research has identified approaches that can be combined to be more effective in transmission reduction than any 1 modality alone: delayed adolescent sexual debut, mutual monogamy or sexual partner reduction, correct and consistent condom use, pre-exposure prophylaxis with oral antiretroviral drugs or vaginal microbicides, voluntary medical male circumcision, antiretroviral therapy (ART) for prevention (including prevention of mother to child HIV transmission [PMTCT]), treatment of sexually transmitted infections, use of clean needles for all injections, blood screening prior to donation, a future HIV prime/boost vaccine, and the female condom. The extent to which evidence-based modalities can be combined to prevent substantial HIV transmission is largely unknown, but combination approaches that are truly implementable in field conditions are likely to be far more effective than single interventions alone. Analogous to PMTCT, "treatment as prevention" for adult-to-adult transmission reduction includes expanded HIV testing, linkage to care, antiretroviral coverage, retention in care, adherence to therapy, and management of key co-morbidities such as depression and substance use. With successful viral suppression, persons with HIV are far less infectious to others, as we see in the fields of sexually transmitted infection control and mycobacterial disease control (tuberculosis and leprosy). Combination approaches are complex, may involve high program costs, and require substantial global commitments. We present a rationale for such investments and cite an ongoing research agenda that seeks to determine how feasible and cost-effective a combination prevention approach would be in a variety of epidemic contexts, notably that in a sub-Saharan Africa.

Examining the evidence on the causal effect of HAART on transmission of HIV using the Bradford Hill criteria

In recent years, evidence has accumulated regarding the ability of HAART to prevent HIV transmission. Early supportive evidence was derived from observational, ecological and population-based studies. More recently, a randomized clinical trial showed that immediate use of HAART led to a 96% decrease in HIV transmission events within HIV serodiscordant heterosexual couples. However, the generalizability of the effect of HAART, and the population-level impact on HIV transmission continues to generate substantial debate. We, therefore, conducted a review of the evidence regarding the preventive effect of HAART on HIV transmission within the context of the Bradford Hill criteria for causality. Taken together, we find the accumulated evidence supporting HIV treatment as prevention meets each of the Bradford Hill criteria for causality. We conclude that the opportunity cost of inaction while waiting for additional evidence on the generalizability of effect in other risk groups is too high. Efforts should be redoubled to mobilize the financial capital and political will to optimize implementation of HIV Treatment as Prevention strategies on a wide scale.

Randomized controlled trial on the effectiveness of counseling messages for avoiding unprotected sexual intercourse during sexually transmitted infection and reproductive tract infection treatment among female sexually transmitted infection clinic patients

BACKGROUND

The effectiveness of counseling messages to avoid unprotected sex during short-term treatment for curable sexually transmitted infections is unknown.

METHODS

We randomized 300 female STI clinic patients 18 years or older with cervicitis and/or vaginal discharge in Kingston, Jamaica, in 2010 to 2011, to 1 of 2 counseling messages for their course of syndromic treatment: abstinence only or abstinence backed up by condom use. At a follow-up visit 6 days afterward, we collected vaginal swabs to test for prostate-specific antigen (PSA), a biological marker of recent semen exposure, and administered a questionnaire assessing sexual behavior.

RESULTS

No differences were found in the proportions of women testing positive for PSA at follow-up in the abstinence-plus-condom group (11.9%) and abstinence-only group (8.4%) (risk difference, 3.5; 95% confidence interval, -3.5 to 10.5). There also was no significant difference in reporting of unprotected sex between groups. Reporting a history of condom use before enrollment significantly modified the effect of counseling arm on PSA positivity (P = 0.03). Among those reporting recent condom use, 10.3% in the abstinence-only arm and 4.8% in the abstinence-plus-condom arm tested positive for PSA. Conversely, among those not reporting recent condom use, 6.5% in the abstinence-only arm and 17.3% in the abstinence-plus-condom arm had PSA detected.

CONCLUSIONS

We found no evidence to support the superiority of either counseling message. Post hoc analyses suggest that women with recent condom experience may benefit significantly more from abstinence-plus-condom messages, whereas women without such experience may benefit significantly more from abstinence-only messages. Providers should weigh individual condom use history when determining the most appropriate counseling message.

Interventions for encouraging sexual behaviours intended to prevent cervical cancer

BACKGROUND

Human papillomavirus (HPV) is the key risk factor for cervical cancer. Continuing high rates of HPV and other sexually transmitted infections (STIs) in young people demonstrate the need for effective behavioural interventions.

OBJECTIVES

To assess the effectiveness of behavioural interventions for young women to encourage safer sexual behaviours to prevent transmission of STIs (including HPV) and cervical cancer.

SEARCH STRATEGY

Systematic literature searches were performed on the following databases: Cochrane Central Register of Controlled Trials (CENTRAL Issue 4, 2009) Cochrane Gynaecological Cancer Review Group (CGCRG) Specialised Register, MEDLINE, EMBASE, CINAHL, PsychINFO, Social Science Citation Index and Trials Register of Promoting Health Interventions (TRoPHI) up to the end of 2009. All references were screened for inclusion against selection criteria.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of behavioural interventions for young women up to the age of 25 years that included, amongst other things, information provision about the transmission and prevention of STIs. Trials had to measure behavioural outcomes (e.g. condom use) and/or biological outcomes (e.g. incidence of STIs, cervical cancer).

DATA COLLECTION AND ANALYSIS

A narrative synthesis was conducted. Meta-analysis was not considered appropriate due to heterogeneity between the interventions and trial populations.

MAIN RESULTS

A total of 5271 references were screened and of these 23 RCTs met the inclusion criteria. Most were conducted in the USA and in health-care clinics (e.g. family planning).The majority of interventions provided information about STIs and taught safer sex skills (e.g. communication), occasionally supplemented with provision of resources (e.g. free sexual health services). They were heterogeneous in duration, contact time, provider, behavioural aims and outcomes. A variety of STIs were addressed including HIV and chlamydia. None of the trials explicitly mentioned HPV or cervical cancer prevention.Statistically significant effects for behavioural outcomes (e.g. increasing condom use) were common, though not universal and varied according to the type of outcome. There were no statistically significant effects of abstaining from or reducing sexual activity. There were few statistically significant effects on biological (STI) outcomes. Considerable uncertainty exists in the risk of bias due to incomplete or ambiguous reporting.

AUTHORS' CONCLUSIONS

Behavioural interventions for young women which aim to promote sexual behaviours protective of STI transmission can be effective, primarily at encouraging condom use. Future evaluations should include a greater focus on HPV and its link to cervical cancer, with long-term follow-up to assess impact on behaviour change, rates of HPV infection and progression to cervical cancer. Studies should use an RCT design where possible with integral process evaluation and cost-effectiveness analysis where appropriate. Given the predominance of USA studies in this systematic review evaluations conducted in other countries would be particularly useful.

Reviewing the evidence on effectiveness and cost-effectiveness of HIV prevention strategies in Thailand

Background

Following universal access to antiretroviral therapy in Thailand, evidence from National AIDS Spending Assessment indicates a decreasing proportion of expenditure on prevention interventions. To prompt policymakers to revitalize HIV prevention, this study identifies a comprehensive list of HIV/AIDs preventive interventions that are likely to be effective and cost-effective in Thailand.

Methods

A systematic review of the national and international literature on HIV prevention strategies from 1997 to 2008 was undertaken. The outcomes used to consider the effectiveness of HIV prevention interventions were changes in HIV risk behaviour and HIV incidence. Economic evaluations that presented their results in terms of cost per HIV infection averted or cost per quality-adjusted life year (QALY) gained were also included. All studies were assessed against quality criteria.

Results

The findings demonstrated that school based-sex education plus life-skill programs, voluntary and routine HIV counselling and testing, male condoms, street outreach programs, needle and syringe programs, programs for the prevention of mother-to-child HIV transmission, male circumcision, screening blood products and donated organs for HIV, and increased alcohol tax were all effective in reducing HIV infection among target populations in a cost-effective manner.

Conclusion

We found very limited local evidence regarding the effectiveness of HIV interventions amongst specific high risk populations. This underlines the urgent need to prioritise health research resources to assess the effectiveness and cost-effectiveness of HIV interventions aimed at reducing HIV infection among high risk groups in Thailand.

Systematic review of interventions to prevent the spread of sexually transmitted infections, including HIV, among young people in Europe

AIM

To examine the effectiveness of interventions seeking to prevent the spread of sexually transmitted infections (STIs), including HIV, among young people in the European Union.

METHODS

For this systematic review, we examined interventions that aimed at STI risk reduction and health promotion conducted in schools, clinics, and in the community for reported effectiveness (in changing sexual behavior and/or knowledge) between 1995 and 2005. We also reviewed study design and intervention methodology to discover how these factors affected the results, and we compiled a list of characteristics associated with successful and unsuccessful programs. Studies were eligible if they employed a randomized control design or intervention-only design that examined change over time and measured behavioral, biologic, or certain psychosocial outcomes.

RESULTS

Of the 19 studies that satisfied our review criteria, 11 reported improvements in the sexual health knowledge and/or attitudes of young people. Ten of the 19 studies aimed to change sexual risk behavior and 3 studies reported a significant reduction in a specific aspect of sexual risk behavior. Two of the interventions that led to behavioral change were peer-led and the other was teacher-led. Only 1 of the 8 randomized controlled trials reported any statistically significant change in sexual behavior, and then only for young females.

CONCLUSION

The young people studied were more accepting of peer-led than teacher-led interventions. Peer-led interventions were also more successful in improving sexual knowledge, though there was no clear difference in their effectiveness in changing behavior. The improvement in sexual health knowledge does not necessarily lead to behavioral change. While knowledge may help improve health-seeking behavior, additional interventions are needed to reduce STIs among young people.

Where to for sexual health education for adolescents in sub-saharan Africa?

Rachel Jewkes discusses disappointing results from a school-based sexual health intervention study in Tanzania and their implications for future health education programs.

Abstinence and teenagers: prevention counseling practices of health care providers serving high-risk patients in the United States

CONTEXT

Abstinence-only education has had little demonstrable impact on teenagers' sexual behaviors, despite significant policy and funding efforts. Given the struggle over resources to improve teenagers' reproductive health outcomes, the views of clinicians serving teenagers at high risk for unintended pregnancy and STDs merit particular attention.

METHODS

In 2005, a qualitative study with 31 clinicians serving low-income, at-risk patients was conducted. A semistructured interview guide was used to ask clinicians about adolescent pregnancy, HIV and STD prevention counseling, and when they include abstinence. Thematic content analysis was used to examine the content of the counseling and the techniques used in different situations.

RESULTS

Providers reported offering comprehensive counseling, presenting abstinence as a choice for teenagers, along with information about contraceptives and condoms. Several providers mentioned that with young, sexually inexperienced teenagers, they discuss delaying sexual activity and suggest other ways to be affectionate, while giving information on condoms. Providers explained how they assess whether teenagers feel ready to be sexually active and try to impart skills for healthy relationships. Some described abstinence as giving teenagers a way to opt out of unwanted sexual activity. Many support abstinence if that is the patient's desire, but routinely dispense condoms and contraceptives.

CONCLUSIONS

Overall, providers did not give abstinence counseling as a rigid categorical concept in their preventive practices, but as a health tool to give agency to teenagers within a harm reduction framework. Their approach may be informative for adolescent policies and programs in the future.

Efficacy of a theory-based abstinence-only intervention over 24 months: a randomized controlled trial with young adolescents

OBJECTIVE

To evaluate the efficacy of an abstinence-only intervention in preventing sexual involvement in young adolescents.

DESIGN

Randomized controlled trial.

SETTING

Urban public schools.

PARTICIPANTS

A total of 662 African American students in grades 6 and 7.

INTERVENTIONS

An 8-hour abstinence-only intervention targeted reduced sexual intercourse; an 8-hour safer sex-only intervention targeted increased condom use; 8-hour and 12-hour comprehensive interventions targeted sexual intercourse and condom use; and an 8-hour health-promotion control intervention targeted health issues unrelated to sexual behavior. Participants also were randomized to receive or not receive an intervention maintenance program to extend intervention efficacy.

OUTCOME MEASURES

The primary outcome was self-report of ever having sexual intercourse by the 24-month follow-up. Secondary outcomes were other sexual behaviors.

RESULTS

The participants' mean age was 12.2 years; 53.5% were girls; and 84.4% were still enrolled at 24 months. Abstinence-only intervention reduced sexual initiation (risk ratio [RR], 0.67; 95% confidence interval [CI], 0.48-0.96). The model-estimated probability of ever having sexual intercourse by the 24-month follow-up was 33.5% in the abstinence-only intervention and 48.5% in the control group. Fewer abstinence-only intervention participants (20.6%) than control participants (29.0%) reported having coitus in the previous 3 months during the follow-up period (RR, 0.94; 95% CI, 0.90-0.99). Abstinence-only intervention did not affect condom use. The 8-hour (RR, 0.96; 95% CI, 0.92-1.00) and 12-hour comprehensive (RR, 0.95; 95% CI, 0.91-0.99) interventions reduced reports of having multiple partners compared with the control group. No other differences between interventions and controls were significant.

CONCLUSION

Theory-based abstinence-only interventions may have an important role in preventing adolescent sexual involvement.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00640653.

A systematic review of the quality of trials evaluating biomedical HIV prevention interventions shows that many lack power

PURPOSE

Several randomized, controlled trials (RCTs) have tested strategies to prevent sexual acquisition of HIV infection, but their quality has been variable. We aimed to identify, describe, and evaluate the quality of RCTs studying biomedical interventions to prevent HIV acquisition by sexual transmission.

METHOD

We conducted a systematic review to identify all RCTs evaluating the efficacy of biomedical HIV prevention interventions. We assessed seven generic and content-specific quality components important in HIV prevention trials, factors influencing study power, co-interventions provided, and trial ethics.

RESULTS

We identified 26 eligible RCTs. The median number of quality components judged to be in adequate or unclear was 3 (range 1-4) in 1992-1998, 3 (range 1-4) in 1999-2003, and 0 (range0-2) in 2004-2008 (p < .001). Common problems that may have biased results included low retention (median 84%), poor adherence to interventions requiring on going use (median < or =78%), and lower HIV incidence than expected a priori (in 8 of 11 trials where evaluable).

CONCLUSION

Reporting of trials of biomedical HIV prevention interventions has improved over time. However, quality improvement is needed in several key areas that influence study power, including participant retention, adherence to interventions, and estimation of expected HIV incidence.

HIV-prevention science at a crossroads: advances in reducing sexual risk

PURPOSE OF REVIEW

We review the current state of evidence-based prevention strategies for reducing sexual transmission of HIV. The combined programmatic and scientific efforts through 2008 to reduce sexual transmission of HIV have failed to reduce substantially the global pandemic.

RECENT FINDINGS

Prevention interventions to reduce HIV infection target behavioral, biomedical, and structural risk factors. Some of these prevention strategies have been evaluated in randomized clinical trials (RCTs) with HIV seroincidence endpoints. When RCTs are not feasible, a variety of observational and quasiexperimental research approaches can provide insight as to program effectiveness of specific strategies. Only five RCTs have demonstrated a notable decrease in sexually acquired HIV incidence. These include the Mwanza study of syndromic management of sexually transmitted diseases and three male circumcision trials in East Africa; a microbicide trial reported in 2009 shows substantial promise for the efficacy of PRO 2000 (0.5% gel).

SUMMARY

The combined programmatic and scientific efforts to reduce sexual transmission of HIV have made incremental progress. New prevention tools are needed to stem the continued spread of HIV, though microbicides and vaccines will take many more years to develop, test, and deploy. Combination strategies of existing modalities should be tested to evaluate the potential for more proximate prevention benefits.

Systematic review of abstinence-plus HIV prevention programs in high-income countries

BACKGROUND

Abstinence-plus (comprehensive) interventions promote sexual abstinence as the best means of preventing HIV, but also encourage condom use and other safer-sex practices. Some critics of abstinence-plus programs have suggested that promoting safer sex along with abstinence may undermine abstinence messages or confuse program participants; conversely, others have suggested that promoting abstinence might undermine safer-sex messages. We conducted a systematic review to investigate the effectiveness of abstinence-plus interventions for HIV prevention among any participants in high-income countries as defined by the World Bank.

METHODS AND FINDINGS

Cochrane Collaboration systematic review methods were used. We included randomized and quasi-randomized controlled trials of abstinence-plus programs for HIV prevention among any participants in any high-income country; trials were included if they reported behavioural or biological outcomes. We searched 30 electronic databases without linguistic or geographical restrictions to February 2007, in addition to contacting experts, hand-searching conference abstracts, and cross-referencing papers. After screening 20,070 abstracts and 325 full published and unpublished papers, we included 39 trials that included approximately 37,724 North American youth. Programs were based in schools (10), community facilities (24), both schools and community facilities (2), health care facilities (2), and family homes (1). Control groups varied. All outcomes were self-reported. Quantitative synthesis was not possible because of heterogeneity across trials in programs and evaluation designs. Results suggested that many abstinence-plus programs can reduce HIV risk as indicated by self-reported sexual behaviours. Of 39 trials, 23 found a protective program effect on at least one sexual behaviour, including abstinence, condom use, and unprotected sex (baseline n = 19,819). No trial found adverse program effects on any behavioural outcome, including incidence of sex, frequency of sex, sexual initiation, or condom use. This suggests that abstinence-plus approaches do not undermine program messages encouraging abstinence, nor do they undermine program messages encouraging safer sex. Findings consistently favoured abstinence-plus programs over controls for HIV knowledge outcomes, suggesting that abstinence-plus programs do not confuse participants. Results for biological outcomes were limited by floor effects. Three trials assessed self-reported diagnosis or treatment of sexually transmitted infection; none found significant effects. Limited evidence from seven evaluations suggested that some abstinence-plus programs can reduce pregnancy incidence. No trial observed an adverse biological program effect.

CONCLUSIONS

Many abstinence-plus programs appear to reduce short-term and long-term HIV risk behaviour among youth in high-income countries. Programs did not cause harm. Although generalisability may be somewhat limited to North American adolescents, these findings have critical implications for abstinence-based HIV prevention policies. Suggestions are provided for improving the conduct and reporting of trials of abstinence-plus and other behavioural interventions to prevent HIV.

Sexual abstinence only programmes to prevent HIV infection in high income countries: systematic review

OBJECTIVE

To assess the effects of sexual abstinence only programmes for HIV prevention among participants in high income countries.

DESIGN

Systematic review.

DATA SOURCES

30 electronic databases without linguistic or geographical restrictions to February 2007, contacts with experts, hand searching, and cross referencing.

REVIEW METHODS

Two reviewers independently applied inclusion criteria and extracted data, resolving disagreements by consensus and referral to a third reviewer. Randomised and quasirandomised controlled trials of abstinence only programmes in any high income country were included. Programmes aimed to prevent HIV only or both pregnancy and HIV. Trials evaluated biological outcomes (incidence of HIV, sexually transmitted infection, pregnancy) or behavioural outcomes (incidence or frequency of unprotected vaginal, anal, or oral sex; incidence or frequency of any vaginal, anal, or oral sex; number of partners; condom use; sexual initiation).

RESULTS

The search identified 13 trials enrolling about 15,940 US youths. All outcomes were self reported. Compared with various controls, no programme affected incidence of unprotected vaginal sex, number of partners, condom use, or sexual initiation. One trial observed adverse effects at short term follow-up (sexually transmitted infections, frequency of sex) and long term follow-up (sexually transmitted infections, pregnancy) compared with usual care, but findings were offset by trials with non-significant results. Another trial observed a protective effect on incidence of vaginal sex compared with usual care, but this was limited to short term follow-up and countered by trials with non-significant findings. Heterogeneity prevented meta-analysis.

CONCLUSION

Programmes that exclusively encourage abstinence from sex do not seem to affect the risk of HIV infection in high income countries, as measured by self reported biological and behavioural outcomes.