Abstinence Programs Fail To Cut Risk Of HIV Infection
Surprise, surprise: programmes that exclusively encourage abstinence from sex do not seem to affect the risk of HIV infection in high income countries, finds a review of the evidence in the British Medical Journal. Scientific evidence against ultraconservative thinking, tis also calls into question the continued use of public money to fund abstinence only programmes in the United States.
Abstinence only programmes encourage sexual abstinence as the exclusive means of preventing HIV infection, without promoting safer sex behaviours, but their effectiveness in high income settings remains unclear.
At present, thirty-three per cent of HIV prevention funds from the US President’s Emergency Plan for AIDS Relief (PEPFAR) are used for abstinence only programmes. This limits the funding available for other safer sex strategies. Domestic US programs also receive substantial federal and state funding.
A pre-existing review has already examined programme effectiveness in low income countries, so researchers at the University of Oxford reviewed 13 trials involving over 15,000 US youths to assess the effects of abstinence only programmes in high income countries.
Programmes aimed to prevent HIV infection or HIV and pregnancy. They measured self reported biological and behavioural outcomes such as sexually transmitted infection, pregnancy, frequency of unprotected sex, number of partners, and sexual initiation.
Compared with various controls, no programme had a beneficial effect on incidence of unprotected vaginal sex, number of partners, condom use, sexual initiation, incidence of pregnancy, or incidence of sexually transmitted infection.
The results also suggest that abstinence only programmes did not increase primary abstinence (prevention) or secondary abstinence (decreased incidence and frequency of recent sex).
Despite some study limitations, these conclusions are consistent with previous reviews that found no evidence of an effect of abstinence only programmes in developing countries or the United States, say the authors. They call for more rigorous evaluations of these programmes in the future.
They also point out that the US Senate has agreed to extend funding of community based abstinence education (CBAE) to $141m which, in view of this evidence, needs to be reconsidered, they argue.
In contrast to abstinence only programmes, 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 infection, say researchers in an accompanying editorial.
They suggest that in the United States priority should be given to 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.
In the developing world the contribution of the “ABC” message (abstinence, be faithful, use a condom) also remains unknown, they conclude.
BMJ 2007;335:248 (4 August), doi:10.1136/bmj.39245.446586.BE (published 26 July 2007), Research
Sexual abstinence only programmes to prevent HIV infection in high income countries: systematic review
Kristen Underhill, research officer, Paul Montgomery, lecturer, Don Operario, lecturer
Centre for Evidence-Based Intervention, University of Oxford, Oxford OX1 2ER
Correspondence to: K Underhill firstname.lastname@example.org
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.