HIV Risk Behavior

Researchers have found that abstinence only sex education programmes in high income countries do not reduce HIV risk behaviour. Investigators from the Centre for Evidence-Based Intervention at Oxford University conducted a systematic analysis of all published studies looking at the effectiveness of abstinence only education. They failed to find any significant evidence that such initiatives reduce the incidence of sexually transmitted infection or pregnancy, or affect sexual behaviour. The study is published in the August 3rd edition of the British Medical Journal. A review of abstinence only education in developing countries presented to last year’s international AIDS conference reached similar conclusions. As there is no effective vaccine for HIV, behavioural interventions to prevent new infections are essential. One such intervention is abstinence only sex education. This encourages individuals – usually teenagers – to refrain from sexual activity until marriage, or to return to abstinence until marriage if they have already initiated sexual relationships. Abstinence programmes differ in their design. Some have the avoidance of pregnancy as their primary outcome, and therefore focus primarily on vaginal intercourse, whereas others are focused on the avoidance of HIV and sexually transmitted infections and counsel abstinence from all forms of sexual activity including anal, oral and vaginal sex. Abstinence only education does not mention condoms as a method of HIV prevention except in the context of their failure rate. By contrast, abstinence plus education also promote the use of condoms. Investigators focused their attention on abstinence only programmes. They noted that such HIV prevention initiatives were the focus of considerable political interest, particularly in the United States and in countries in receipt of funds from the Presidential Emergency Plan for AIDS Relief (PEPFAR). The exclusion of broadly-based safer sex initiatives from PEPFAR funding has occasioned intense controversy. However, debates about abstinenc- only education have often occurred without reference to methodologically rigorous evidence. Therefore investigators from Oxford University decided to conduct an “apolitical, up to date systematic review” of studies looking at abstinence only education in richer countries. They hypothesised that such countries would have conditions favourable to abstinence-only education. Investigators searched through 30 electronic databases and the proceedings of conferences to identify randomised controlled trials looking at the biological (i.e. avoidance of HIV or sexually transmitted infections) and behavioural (avoidance of sexual activity) effectiveness of abstinence education. They also expanded their search to include on-going or recently completed studies. A total of 13 studies were identified. All were conducted in the United States. Eight involved ethnically mixed populations, and five had mainly white participants. None assessed outcomes by reported sexual orientation. Reported sexual behaviours were limited to vaginal sex. None of the studies gathered information on anal or oral intercourse. Nor did any of the studies include testing for HIV or sexually transmitted infections, relying on self-report of sexually transmitted infections or pregnancy. None of the studies found that abstinence-only education protected individuals from self-reported sexually transmitted infections in either the short or longer term. Indeed, one study found that adolescents who received abstinence only education had an increased risk of sexually transmitted infections after three and 17 months. Similarly, none of the studies found that abstinence only education reduced the incidence of self-reported pregnancy. The investigators then turned their attention to behavioural outcomes. Five studies assessed the incidence of unprotected vaginal sex. None found a protective effect of abstinence education. Seven studies looked at the incidence of any vaginal sex, and although one study did find that abstinence only education had a positive effect, it had severe methodological limitations as more participants reported having sex in the previous month than ever having had sex. Four studies looked at the frequency of vaginal sex. None found that abstinence only education was effective, indeed one found the opposite. Eight studies examined whether abstinence only education reduced numbers of sexual partners. Yet again, no beneficial effect was observed. None of the studies promoted condom use, and unsurprisingly, there was no evidence that abstinence only education yielded greater use of condoms or more consistent condom use. Nor did abstinence education have any effect on sexual initiation, an issue that was explored in ten studies. One recently completed study did, however, find that adolescents who received abstinence only education were significantly less likely to report vaginal sex. However, the investigators note “these findings are offset by the non-significant findings of ten included trials in out review.” “Evidence from this review suggests that abstinence only programmes that aim to prevent HIV infection are ineffective”, write the authors. They caution, “the generalisability of these results may be limited to the United States.” They suggest that “evidence from this review might inform ongoing assessments of US policy on abstinence only interventions, which have received federal funding since 1981.” The authors of an accompanying editorial write, “when compared with various control groups, there was little evidence that risky sexual behaviour, including sexually transmitted infections, or pregnancy were reduced in adolescents in abstinence only programmes. Abstinence only programmes did not increase primary abstinence or secondary abstinence.” They continue, “in contrast…programmes that promote the use of condoms greatly reduce the risk of acquiring HIV, especially when such programmes are culturally tailored behavioural interventions targeting people at highest risk of HIV.” As a result, the authors believe the US should prioritise “culturally sensitive, sex specific, behavioural interventions that target black and Hispanic patients in clinics for sexually transmitted infections, men who have sex with men, and adolescents being treated for drug misuse who are at highest risk of acquiring HIV.” Reference Underhill K et al. Sexual abstinence only programmes to prevent HIV infection in high income countries: systematic review. British Medical Journal (online edition), August 3rd, 2007. Hawes EH et al. Is there a role for abstinence only programmes for HIV prevention in high income countries? British Medical Journal (online edition), August 3rd, 2007