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.

[1]  Douglas G. Altman,et al.  The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomised trials , 2001, The Lancet.

[2]  M. Rotheram-Borus,et al.  Prevention of HIV Among Adolescents , 2000, Prevention Science.

[3]  J. Udry,et al.  Adolescents' Honesty in a Survey of Sexual Behavior , 1988 .

[4]  L. Kann,et al.  Assessing health risk behaviors among adolescents: the effect of question wording and appeals for honesty. , 2004, The Journal of adolescent health : official publication of the Society for Adolescent Medicine.

[5]  W. Chavkin.  Sex, lies, and silence: reproductive health in a hostile environment. , 2001, American journal of public health.

[6]  L. Hedges,et al.  Meta‐analysis of the Effects of Behavioral HIV Prevention Interventions on the Sexual Risk Behavior of Sexually Experienced Adolescents in Controlled Studies in the United States , 2002, Journal of acquired immune deficiency syndromes.

[7]  J. Zarocostas.  Migration of health workers from less developed countries needs urgent solution, say experts , 2006, BMJ : British Medical Journal.

[8]  B. Fiese,et al.  HIV Sexual Risk-Reduction Interventions for Youth: A Review and Methodological Critique of Randomized Controlled Trials , 2003, Behavior modification.

[9]  G. Guyatt,et al.  Users' guides to the medical literature. , 1993, JAMA.

[10]  G. Guyatt,et al.  Interventions to reduce unintended pregnancies among adolescents: systematic review of randomised controlled trials , 2002, BMJ : British Medical Journal.

[11]  Z. Kmietowicz.  Commission invites discussion on the future of genetics in reproduction , 2004, British medical journal.

[12]  P. Goodson,et al.  Defining abstinence: views of directors, instructors, and participants in abstinence-only-until-marriage programs in Texas. , 2003, The Journal of school health.

[13]  Mónica Silva.  The effectiveness of school-based sex education programs in the promotion of abstinent behavior: a meta-analysis. , 2002, Health education research.

[14]  A. O'Leary,et al.  Measurement of condom use self-efficacy and outcome expectancies in a geographically diverse group of STD patients. , 1997, AIDS education and prevention : official publication of the International Society for AIDS Education.

[15]  H. Jaffe.  Whatever Happened to the U.S. AIDS Epidemic? , 2004, Science.

[16]  N. Goldman,et al.  Teenage pregnancy in developed countries: determinants and policy implications. , 1985, Family planning perspectives.

[17]  D. Moher,et al.  The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomized trials. , 2001, Journal of the American Podiatric Medical Association.

[18]  Trevor Stammers.  Sexual health in adolescents. "Saved sex" and parental involvement are key to improving outcomes [editorial] , 2007 .

[19]  Lauritsen Jl,et al.  The Consistency of Self-Reported Initiation of Sexual Activity , 1997 .

[20]  D. Kirby.  School-based programs to reduce sexual risk-taking behaviors. , 1992, The Journal of school health.

[21]  G. Swingler,et al.  Cotrimoxazole prophylaxis for opportunistic infections in adults with HIV. , 2003, The Cochrane database of systematic reviews.

[22]  D. Kirby,et al.  The Impact of Sex and HIV Education Programs in Schools and Communities on Sexual Behaviors among Young Adults , 2006 .

[23]  Mark Thomas,et al.  Abstinence-based programs for prevention of adolescent pregnancies. A review. , 2000, The Journal of adolescent health : official publication of the Society for Adolescent Medicine.

[24]  L. Jemmott,et al.  HIV risk reduction behavioral interventions with heterosexual adolescents. , 2000, AIDS.

[25]  Depression & HIV: assessment and treatment. , 1997, STEP perspective.

[26]  A R Jadad,et al.  Assessing the quality of reports of randomized clinical trials: is blinding necessary? , 1996, Controlled clinical trials.

[27]  Ron Haskins,et al.  Abstinence Education under Welfare Reform , 1997 .

[28]  G. Guyatt,et al.  Users' Guides to the Medical Literature: IX. A Method for Grading Health Care Recommendations , 1995 .

[29]  K. Underhill,et al.  Abstinence-plus programs for HIV infection prevention in high-income countries. , 2007, The Cochrane database of systematic reviews.

[30]  Judith Stephenson,et al.  Why do we need randomised controlled trials to assess behavioural interventions? , 1998, BMJ.

[31]  Mike Clarke,et al.  Is Evidence-Based Medicine Relevant to the Developing World? , 2005, Evidence-based complementary and alternative medicine : eCAM.

[32]  Blair T. Johnson,et al.  Sexual Risk Reduction Interventions Do Not Inadvertently Increase the Overall Frequency of Sexual Behavior: A Meta-analysis of 174 Studies With 116,735 Participants , 2006, Journal of acquired immune deficiency syndromes.

[33]  D. Kirby.  Sexuality education: a more realistic view of its effects. , 1985, The Journal of school health.

[34]  D. Nutt,et al.  Does blinding of readers affect the results of meta-analyses? , 1997 .

[35]  D. Kirby.  Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy (Summary) , 2001 .

[36]  B. Huberman,et al.  Lessons Learned: European Approaches to Adolescent Sexual Behavior and Responsibility , 2000 .

[37]  J. Tanne.  New US abstinence programme guidelines criticised , 2006, BMJ : British Medical Journal.

[38]  J. Rosenbaum.  Reborn a virgin: adolescents' retracting of virginity pledges and sexual histories. , 2006, American journal of public health.

[39]  W A Fisher,et al.  Changing AIDS-risk behavior. , 1992, Psychological bulletin.

[40]  L. Hedges,et al.  A Protocol for the Analytical Aspects of a Systematic Review of HIV Prevention Research , 2002, Journal of acquired immune deficiency syndromes.

[41]  J. Reinisch,et al.  Would you say you "had sex" if...? , 1999, JAMA.

[42]  R. Walgate.  Bush's AIDS plan criticised for emphasising abstinence and forbidding condoms , 2004, BMJ : British Medical Journal.

[43]  Neff Walker,et al.  The global impact of HIV/AIDS , 2001, Nature.

[44]  J. Shoveller,et al.  Preventing HIV/AIDS Risk Behavior Among Youth , 2002, AIDS and Behavior.

[45]  D. Celentano,et al.  The social epidemiology of human immunodeficiency virus/acquired immunodeficiency syndrome. , 2004, Epidemiologic reviews.

[46]  J. Santelli,et al.  Explaining recent declines in adolescent pregnancy in the United States: the contribution of abstinence and improved contraceptive use. , 2007, American journal of public health.

[47]  Deirdre A. Fullerton,et al.  Sexual health education interventions for young people: a methodological review , 1995, BMJ.

[48]  J. Deeks,et al.  Male circumcision for prevention of heterosexual acquisition of HIV in men. , 2011, The Cochrane database of systematic reviews.

[49]  L. Zabin,et al.  Adolescent sexual attitudes and behavior: are they consistent? , 1984, Family planning perspectives.

[50]  M. Sherif,et al.  The psychology of attitudes. , 1946, Psychological review.

[51]  R. DiClemente.  The Emergence of Adolescents as a Risk Group for Human Immunodeficiency Virus Infection , 1990 .

[52]  P. Aggleton,et al.  HIV Prevention in Industrialized Countries , 2000 .

[53]  K. Ethier,et al.  Behavioral interventions to reduce incidence of HIV, STD, and pregnancy among adolescents: a decade in review. , 2004, The Journal of adolescent health : official publication of the Society for Adolescent Medicine.

[54]  D. Kirby.  The impact of schools and school programs upon adolescent sexual behavior , 2002, Journal of sex research.

[55]  R. West.  Does blinding of readers affect results of meta-analyses? , 1997, The Lancet.

[56]  D. Nutt,et al.  Adult night terrors and paroxetine , 1997, The Lancet.

[57]  L. Remez.  Oral sex among adolescents: is it sex or is it abstinence? , 2000, Family planning perspectives.

[58]  Using Behavioral Theories to Design Abstinence Programs , 1997 .

[59]  T. Greenhalgh,et al.  Education and debate , 1997 .

[60]  Kristin Haglund.  Sexually abstinent African American adolescent females' descriptions of abstinence. , 2003, Journal of nursing scholarship : an official publication of Sigma Theta Tau International Honor Society of Nursing.

[61]  R. Gold,et al.  States' implementation of the Section 510 abstinence education program, FY 1999. , 2001, Family planning perspectives.

[62]  K. Underhill,et al.  Reporting deficiencies in trials of abstinence-only programmes for HIV prevention. , 2007, AIDS.

[63]  R. DiClemente.  Preventing sexually transmitted infections among adolescents: a clash of ideology and science. , 1998, JAMA.

[64]  A. O'Leary,et al.  Reflections on the design and reporting of STD/HIV behavioral intervention research. , 1997, AIDS education and prevention : official publication of the International Society for AIDS Education.

[65]  N. Assefi,et al.  School-based teenage pregnancy prevention programs: a systematic review of randomized controlled trials. , 2005, The Journal of adolescent health : official publication of the Society for Adolescent Medicine.

[66]  R. Maynard,et al.  The Evaluation of Abstinence Education Programs Funded Under Title V Section 510. Interim Report. Princeton, NJ: Mathematica Policy Research , 2002 .

[67]  Jesse A Berlin,et al.  Does blinding of readers affect the results of meta-analyses? , 1997, The Lancet.

[68]  Janet L. Lauritsen,et al.  The consistency of self-reported initiation of sexual activity. , 1997, Family planning perspectives.

[69]  R. Rector.  The Effectiveness of Abstinence Education Programs in Reducing Sexual Activity Among Youth , 2002 .

[70]  Lillian S. Lin,et al.  Does Measured Behavior Reflect STD Risk?: An Analysis of Data From a Randomized Controlled Behavioral Intervention Study , 2000, Sexually transmitted diseases.