Research Article: Systematic Review of Abstinence-Plus HIV Prevention Programs in High-Income Countries

Date Published: September 18, 2007

Publisher: Public Library of Science

Author(s): Kristen Underhill, Don Operario, Paul Montgomery, Thomas Coates

Abstract: BackgroundAbstinence-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 FindingsCochrane 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 After screening 20,070 abstracts and 325 full published and unpublished papers, we included 39 trials that included approximately 37,724 North American youth.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.ConclusionsMany 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.

Partial Text: Although the HIV epidemic is most devastating in middle- and low-income countries, new infections continue multiplying even in countries with many resources for prevention [1]. The World Health Organization estimated in 2004 that 1.6 million people in high-income countries were living with HIV [2]; by 2006, approximately 2.1 million individuals in North America, Western Europe, and Central Europe were HIV-positive [3]. Sexual behaviour is the most common transmission route in high-income countries, and primary prevention efforts remain crucial among high-risk groups and the general population.

The search retrieved 20,070 records (i.e., citations and abstracts), of which 330 were deemed potentially relevant evaluations by any reviewer (Figure 1). We successfully obtained full versions of 325 reports. After excluding reports based on study design, intervention description, and outcomes of interest, we included 39 trials [62–100] from 37 separate primary papers. Seven trials were unpublished [71,73,76,80,84,89,100], and conference presentations constituted the primary source of information for three evaluations [71,80,84]. We included conference presentations when we were able to obtain missing data from authors or when there was no evidence of selective reporting of results. Authors were contacted on multiple occasions for missing information. Data were also extracted from supplementary papers where possible (Danella, et al. unpublished data and [101–122]).

The 39 included trials (baseline n ≈ 37,724) showed no evidence that abstinence-plus programs increase HIV risk among youth participants in high-income countries, and multiple evaluations found that the programs can decrease HIV risk. In 24 trials (baseline n = 20,982) significantly protective program effects were observed for behavioural [62–69,71,73,74,77–80,84,85,88,90,91,94,95,98] or biological [64,89] outcomes.



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