School based sex education and HIV prevention in low- and middle-income countries: a systematic review and meta-analysis

Trends in participation in teen pregnancy and STI prevention programming, 2002-2016

Programs designed to help youth prevent early/unwanted pregnancy and sexually transmitted infection (STI) have been shown to yield a positive impact on youth behavior and key outcomes. However, recent evidence suggests that youth participation in prevention programming for health-risk behavior may be declining. The aim of the present study is to provide up-to-date information on the national trends in adolescent participation in prevention programming targeting early pregnancy and STI in the United States. We examined fifteen years of cross-sectional data (2002-2016, N = 234,803) from the National Survey on Drug Use and Health. Our main outcome was youth self-reported (no/yes) past-year participation in a pregnancy or STI prevention program. Survey adjusted prevalence estimates and logistic regression analysis were used to examine trends in participation. Youth participation in pregnancy and STI prevention programming decreased significantly from a high of 15% in 2003 to a low of 7% in 2016. Representing a 53% proportional decline in youth participation, this downward trend was significant even when controlling for age, gender, race/ethnicity, household income, and urbanicity (AOR: 0.947, 95% CI: 0.943-0.951). The downward trend in participation was observed across racial/ethnic subgroups. A consistent pattern of differences in prevalence was observed with African-American youth reporting the highest levels of participation followed by Hispanic, and then White youth. It is incumbent upon concerned citizens, scientists, and policymakers to push for change that can shift the trend line in adolescent participation in teen pregnancy and STI prevention programming to an upward tilt.

"We know this will be hard at the beginning, but better in the long term": understanding PrEP uptake in the general population in Eswatini

Information regarding HIV pre-exposure prophylaxis (PrEP) for the general population is largely lacking, because the majority of PrEP demonstration projects have focused on key populations. This qualitative study examines barriers and facilitators to PrEP uptake and adherence among the general population in Eswatini, where PrEP is offered through public-sector primary-care clinics. We analysed 106 semi-structured in-depth interviews with healthcare workers (n = 26), stakeholders (n = 30), and clients who initiated, continued, declined or discontinued PrEP (n = 50). Some healthcare workers and stakeholders feared that PrEP would reduce condom use and cause drug resistance, while some clients feared possible side effects and the reaction of family members when learning of PrEP use. At the same time, respondents across all groups valued that PrEP could be taken without partner knowledge or consent, and that PrEP was available via public sector clinics. Clients felt that PrEP relieved the fear of HIV infection and thus bolstered enjoyment during sex. Overall, respondents described the general population approach to PrEP delivery as enabling and life-improving, despite the above concerns. Respondents recommended to create community PrEP promotion and delivery, gain community leaders' approval and understanding of PrEP, shorten the PrEP initiation process, and target men and adolescent girls.

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.

Do School-Based Programs Prevent HIV and Other Sexually Transmitted Infections in Adolescents? A Systematic Review and Meta-analysis

We systematically reviewed the literature to assess the effectiveness of school-based programs to prevent HIV and other sexually transmitted infections (STI) among adolescents in the USA. We searched six databases including PubMed for studies published through May 2017. Eligible studies included youth ages 10-19 years and assessed any school-based programs in the USA that reported changes in HIV/STI incidence or testing. We used Cochrane tool to assess the risk of bias and GRADE to determine the evidence quality for each outcome. Three RCTs and six non-RCTs, describing seven interventions, met study inclusion criteria. No study reported changes in HIV incidence or prevalence. One comprehensive intervention, assessed in a non-RCT and delivered to pre-teens, reduced STI incidence into adulthood (RR 0.36, 95% CI 0.23-0.56). A non-RCT examining chlamydia and gonorrhea incidence before and after a condom availability program found a significant effect at the city level among young men 3 years later (RR 0.43, 95% CI 0.23-0.80). The remaining four interventions found no effect. The effect on STI prevalence was also not significant (pooled RR 0.83 from two non-RCTs, RR 0.70 from one RCT). Only one non-RCT showed an increase in HIV testing (RR 3.19, 95% CI 1.24-8.24). The quality of evidence for all outcomes was very low. Studies, including the RCTs, were of low methodological quality and had mixed findings, thus offering no persuasive evidence for the effectiveness of school-based programs. The most effective intervention spanned 6 years, was a social development-based intervention with multiple components, rather than a sex education program, and started in first grade.

Evaluation of a comprehensive sexuality education program in La Romana, Dominican Republic

BACKGROUND

The Dominican Republic (DR) has some of the highest rates of sexually transmitted infections (STI) and adolescent pregnancy in the Caribbean. Well-designed comprehensive sexuality education programs (CSEP) can reduce risky sexual behavior. This study sought to evaluate the Módulo Anexo Materno Infantil (MAMI) adolescent clinic's CSEP in changing knowledge of STI and pregnancy and attitudes towards risky sexual behavior following implementation.

METHODS

A mixed methods study was conducted among students aged 11-25 years from three schools between September 2017 and February 2018. Participants in MAMI CSEP completed questionnaires, before, immediately following, and 3 months following the CSEP. Questions assessed knowledge, attitude, and sexual experience, and obtained program feedback. There was one eight-participant focus group discussion (FGD) per school. Descriptive statistics summarized sample demographics and cross-sectional responses. McNemar's test evaluated differences in the proportions of students selecting correct responses over time. Paired t-tests compared mean test scores across time.

RESULT

Overall response rate was 98.7% (1414/1432), with 486 pre-tests, 448 initial post-tests, and 480 3-month post-tests. Respondents identified as 53.5% (321/600) female and 46.5% (279/600) male with mean age of 14.2 years. More males (63.4%) reported sexual experience than females (35.8%) (p < 0.001). Increases in mean scores from pre-test to post-test and pre-test to 3-month post-test were statistically significant (p < 0.001). Three themes arose from the FGDs: (1) expanding sexual and reproductive health knowledge, (2) perception of curricular content, structure and delivery, and (3) student-health educator dynamic.

CONCLUSION

Improvement in test scores supports MAMI CSEP's efficacy in educating students and reinforcing positive attitudes to reduce risky sexual behavior. Utilizing an interactive health educator model provided students with clear, accurate information in a safe environment with mutual trust. Selecting health educators employed by an adolescent clinic allows them to connect students to preventive and treatment services during the CSEP.

Perceptions of Sexual Infidelity in Rural Cambodia: A Qualitative Study of Adolescent Men

Sexual infidelity plays a significant role in the high rate of spousal transmission of HIV in Cambodia. The sexual beliefs and attitudes of a person begin in childhood and are developed through multiple chains in early adolescence, affecting his or her future sexual behavior and future incidence of HIV. A deeper understanding of the perspectives of adolescents regarding infidelity is critical to effective HIV prevention efforts during adulthood. Using a descriptive qualitative approach, this study explored the perceptions of male adolescents regarding male infidelity. Through the thematic analysis method, themes and subcategories were developed from the responses of 48 male high school students from three provinces. Majority of the participants ( n = 33) were found to have liberal attitudes not only toward male infidelity but also toward the high possibility of their own future infidelity ( n = 14). Almost 45% ( n = 21) of the participants explained that men would fulfill their sexual desires outside, such as in karaoke, when their wives are unable to have sex with them. Participants believed it annoying for men to disclose their extramarital activities to their wives. The study concluded that the participants hold accepting perceptions about infidelity; they are part of the HIV problem and must be part of the solution. Educators and counselors need to deliver age-appropriate, scientifically correct, and culturally relevant messages about sexual health and HIV prevention to growing adolescents.

Acceptability and challenges of introducing an educational audio-drama about gender violence and HIV prevention into schools in Botswana: an implementation review

Structural interventions for HIV prevention are typically complex and evaluation should include measurement of implementation. In a trial of a structural intervention for HIV prevention in Botswana we trained teachers to use an audio-drama about gender violence and HIV (BVV). We measured the use of BVV by the trained teachers, and the factors related. In three-day workshops we trained guidance teachers in primary and secondary schools to use the 8-episode BVV audio-drama, that covers gender, gender violence and HIV. One to two years later, two interviewers visited schools and administered an electronic questionnaire to the head teacher and to the BVV-trained teacher. Most teachers (70%, 72/103) had used the BVV materials and reported a positive response from students. Primary school teachers were less likely to have used BVV (adjusted odds ratio (ORa) 0.24, 95% cluster adjusted confidence interval (CIca) 0.07-0.88). Teachers in schools with a working MP3 player were more likely to have used BVV (ORa 3.75, 95% CIca 1.11-12.70). Implementation was much lower in one district (ORa 0.12, 95% CIca 0.04-0.36), related to language constraints. The main difficulty was lack of time, especially in primary schools. These findings could inform rollout of the BVV programme in schools. Abbreviations: BVV: Beyond Victims and Villains audio-drama; CI: Confidence interval; OR: Odds ratio.

A cross-sectional mixed-methods study of sexual and reproductive health knowledge, experiences and access to services among refugee adolescent girls in the Nakivale refugee settlement, Uganda

Abstract

Background

Humanitarian crises and migration make girls and women more vulnerable to poor sexual and reproductive health (SRH) outcomes. Nevertheless, there is still a dearth of information on SRH outcomes and access to SRH services among refugee girls and young women in Africa. We conducted a mixed-methods study to assess SRH experiences, knowledge and access to services of refugee girls in the Nakivale settlement, Uganda.

Methods

A cross-sectional survey among 260 adolescent girls 13–19 years old was conducted between March and May 2018. Concurrently, in-depth interviews were conducted among a subset of 28 adolescents. For both methods, information was collected regarding SRH knowledge, experiences and access to services and commodities. The questionnaire was entered directly on the tablets using the Magpi® app. Descriptive statistical analysis and multinomial logistic regression were performed. Qualitative data was transcribed and analysed using thematic content analysis.

Results

A total of 260 participants were interviewed, with a median age of 15.9 years. The majority of girls were born in DR Congo and Burundi. Of the 93% of girls who had experienced menstruation, 43% had ever missed school due to menstruation. Regarding SRH knowledge, a total of 11.7% were not aware of how HIV is prevented, 15.7% did not know any STI and 13.8% were not familiar with any method to prevent pregnancy. A total of 30 girls from 260 were sexually active, of which 11 had experienced forced sexual intercourse. The latter occurred during conflict, in transit or within the camp. A total of 27 of 260 participants had undergone female genital mutilation (FGM). The most preferred sources for SRH information was parents or guardians, although participants expressed that they were afraid or shy to discuss other sexuality topics apart from menstruation with parents. A total of 30% of the female adolescents had ever visited a SRH service centre, mostly to test for HIV and to seek medical aid for menstrual problems.

Conclusions

Adolescent refugee girls lack adequate SRH information, experience poor SRH outcomes including school absence due to menstruation, sexual violence and FGM. Comprehensive SRH services including sexuality education, barrier-free access to SRH services and parental involvement are recommended.

Electronic supplementary material

The online version of this article (10.1186/s12978-019-0698-5) contains supplementary material, which is available to authorized users.

A Systematic Global Review of Condom Availability Programs in High Schools

PURPOSE

High levels of HIV, sexually transmitted infections (STIs), and pregnancy among adolescents has motivated some countries to consider the implementation of condom availability programs (CAPs) in high schools. In this present study, we analyzed the impact of CAP on students' sexual behaviors and health outcomes.

METHODS

We conducted a systematic literature review of peer-reviewed articles published between 1990 and 2017.

RESULTS

Twenty-nine articles from seven countries were included in this review. We found that CAP does not increase sexual activity nor lead to a greater number of sexual partners. It also does not lower the age of sexual initiation. A majority of the studies reported an increase in condom uptake and use at last sex among students with CAP. All the studies that examined STI found a decrease of STI symptoms and rates for students with CAP compared with the control group. The data on HIV rates was inconclusive. There was no difference in pregnancy rates associated with participation in CAP programs.

CONCLUSION

This global literature review showed that the fears surrounding CAP and promiscuity are unfounded. Once CAP is in place, students utilize it, and condom use increases, which translates to improved sexual health outcomes.

The effectiveness of using entertainment education narratives to promote safer sexual behaviors of youth: A meta-analysis, 1985-2017

BACKGROUND

Risky sexual behaviors are associated with the transmission of sexually transmitted infections (STIs) and unwanted pregnancies, both major health concerns for youth worldwide. This review studies the effectiveness of narrated mass media programs in promoting safer sexual practices among youth in developed and developing countries.

METHODS

Electronic and manual searches were conducted to identify experimental and quasi-experimental studies with robust counterfactual designs published between 1985 and the first quarter of 2017. Effect sizes were meta-analyzed using mixed-effects models.

RESULTS

Eight experimental and two quasi-experimental studies met our inclusion criteria. The aggregated sample size was 23,476 participants, with a median of 902 participants per study. Entertainment education narratives had small but significant effects for three sexual behaviors. It reduced the number of sexual partners [standardized mean difference, (SMD) = 0.17, 95% confidence interval (CI) = 0.02-0.33, three effect sizes], reduced unprotected sex (SMD = 0.08, 95% CI = 0.03-0.12, nine effect sizes), and increased testing and management for STIs (SMD = 0.29, 95% CI = 0.11-0.46, two effect sizes). The interventions were not effective in reducing inter-generational sex, measured through the age-gap with sexual partners (SMD = 0.06, 95% CI = -0.06-0.19, four effect sizes). Entertainment education had medium-size effects on knowledge outcomes (SMD = 0.67, 95% CI = 0.32-1.02, seven effect sizes), where a time-decay relationship is observed. No effects were found on attitudes.

CONCLUSION

Although mass media entertainment had small effects in promoting safer sexual practices, its economies of scales over face-to-face interventions suggest its potential to be a cost-effective tool above an audience threshold. The use of study participants from the general youth population and the use of mostly effectiveness trials mitigate concerns regarding its scalability. The overall paucity of high-quality studies affirms the need for strengthening the evidence base of entertainment education. Future research should be undertaken to understand the moderator effects for different subgroups and intervention characteristics.

Adaptation of an effective school-based sexual health promotion program for youth in Colombia

RATIONALE

Given the disproportionate impact of HIV and STIs among youth in Latin America, there is a compelling need for effective sex education programs. In particular, Colombia lacks a nationally standardized youth sex education program, despite the fact that 15 to 24-year-olds accounted for the highest incidence and prevalence rates of HIV and STIs in the nation. In an attempt to fill this void, our team adapted COMPAS, a Spanish school-based sexual health promotion intervention, for Colombian adolescents.

OBJECTIVE

This study describes the adaptation process that resulted in a modified version of COMPAS for youth in Colombia.

METHOD

We employed a systematic cultural adaptation process utilizing a mixed methods approach, including intervention adaptation sessions with 100 young adolescents aged 15-19. The process included six steps: 1) consulting international researchers and community stakeholders; 2) capturing the lived experiences of a diverse sample of colombian youth; 3) identifying priorities and areas in need of improvement; 4) integrating the social cognitive theory, information-motivation-behavioral skills model, and an ecological framework for colombian youth; 5) adapting intervention content, activities, and materials; and 6) quantitative evaluation of COMPAS by Colombian youth.

RESULTS

The adapted intervention incorporates elements common to effective youth sex education interventions, including: a solid theoretical foundation, sexual communication skills and social support for protection, and guidance on how to utilize available cultural- and linguistic-appropriate services. In addition, the adapted intervention incorporates cultural and linguistic appropriate content, including an emphasis on tackling machismo to promote risk reduction behaviors.

CONCLUSIONS

The systematic adaptation approach to sexual health intervention for youth can be employed by researchers and community stakeholders in low-resource settings for the promotion of health wellness, linkage to care, and STI and unplanned pregnancy prevention for youth.

The Evidence Project risk of bias tool: assessing study rigor for both randomized and non-randomized intervention studies

BACKGROUND

Different tools exist for assessing risk of bias of intervention studies for systematic reviews. We present a tool for assessing risk of bias across both randomized and non-randomized study designs. The tool was developed by the Evidence Project, which conducts systematic reviews and meta-analyses of behavioral interventions for HIV in low- and middle-income countries.

METHODS

We present the eight items of the tool and describe considerations for each and for the tool as a whole. We then evaluate reliability of the tool by presenting inter-rater reliability for 125 selected studies from seven published reviews, calculating a kappa for each individual item and a weighted kappa for the total count of items.

RESULTS

The tool includes eight items, each of which is rated as being present (yes) or not present (no) and, for some items, not applicable or not reported. The items include (1) cohort, (2) control or comparison group, (3) pre-post intervention data, (4) random assignment of participants to the intervention, (5) random selection of participants for assessment, (6) follow-up rate of 80% or more, (7) comparison groups equivalent on sociodemographics, and (8) comparison groups equivalent at baseline on outcome measures. Together, items (1)-(3) summarize the study design, while the remaining items consider other common elements of study rigor. Inter-rater reliability was moderate to substantial for all items, ranging from 0.41 to 0.80 (median κ = 0.66). Agreement between raters on the total count of items endorsed was also substantial (κw = 0.66).

CONCLUSIONS

Strengths of the tool include its applicability to a range of study designs, from randomized trials to various types of observational and quasi-experimental studies. It is relatively easy to use and interpret and can be applied to a range of review topics without adaptation, facilitating comparability across reviews. Limitations include the lack of potentially relevant items measured in other tools and potential threats to validity of some items. To date, the tool has been applied in over 30 reviews. We believe it is a practical option for assessing risk of bias in systematic reviews of interventions that include a range of study designs.

Association between receipt of school-based HIV education and contraceptive use among sexually active high school students - United States, 2011-2013

Sexual health education, including HIV prevention information, can help prevent unintended pregnancy and sexually transmitted infections. National Youth Risk Behavior Survey data from 2011 and 2013 were used to determine HIV education prevalence among 9,825 currently sexually active students in grades 9-12. Associations between HIV education and contraceptive methods used at last sexual intercourse were examined for: (1) condom use; (2) any contraceptive method; (3) dual use of a condom and either birth control pills; IUD or implant; or shot, patch, or birth control ring; and (4) primary contraceptive method. Primary contraceptive method options were (1) no method; (2) birth control pills; (3) condoms; (4) IUD or implant; (5) shot, patch, or birth control ring; (6) withdrawal or some other method; and (7) not sure. Logistic regression (prevalence ratios [PRs] and 95% confidence intervals [CIs]) and Chi-squares were used for testing. Students who received HIV education were more likely than students who did not to use a condom (PR:1.09;CI:1.01,1.18) and any contraceptive method (PR:1.08;CI:1.04,1.12); there was no significant association with dual use. Primary contraceptive method varied significantly by receipt of HIV education (p < .001). School-based HIV education may be important for promotion of adolescent condom and contraceptive use.

Teachers' competence, school policy and social context-HIV prevention needs of primary schools in Kagera, Tanzania

Sub-Saharan Africa carries a high burden of the HIV epidemic, with young adults being particularly affected. Well-designed school-based HIV prevention interventions can contribute to establishing protective behaviour. The aim of this study was to explore the needs of primary school students and teachers in the region of Kagera, Tanzania, regarding an HIV prevention intervention in the primary school setting. The needs assessment was structured according to the PRECEDE component of the PRECEDE-PROCEED model. Qualitative data was collected in six focus group discussions with primary school students and teachers. Key informant interviews with seven experts were conducted. We employed qualitative content analysis to analyse data in MAXQDA. The findings suggest that teachers need to be adequately trained to provide HIV and sex education and to support HIV-positive students. Enabling structural factors, such as an appropriate syllabus, are required. Stigmatization has been reported a major barrier to HIV prevention in schools. Teachers and students identified a more trustful relationship between each other as well as to legal guardians of children as a basis for HIV prevention. These findings will inform the development of a tailored HIV prevention intervention.

Knowledge and risk perception of sexually transmitted infections and relevant health care services among high school students in the Platfontein San community, Northern Cape Province, South Africa

Background

The historically marginalized Platfontein San youths have a high rate of teenage pregnancies and sexually transmitted infections (STIs). The aim of the study was to assess the knowledge and perception of male and female school-going youths in Platfontein of STIs and HIV/AIDS, and the health care services that are available to them.

Participants and methods

A descriptive cross-sectional survey with a sample of 201 learners in grades 6–12 at the !Xunkwesa Combined School in Platfontein was conducted in July 2007. A pretested self-administered questionnaire was used for data collection.

Results

The study found that STI knowledge was 70.1% and HIV and AIDS was 11.9%. Perceptions of risk among the learners were uniformly low; 24% for contracting a STI and 26% for HIV. About 59% (n=119) of the respondents were either unaware or not sure of the primary health care (PHC) services within the community. Overall, 65% of the students reported using PHC services while 35% exclusively used traditional healers. Slightly less than half (43%) of the learners acquired information about sexual and reproductive health through the Life Skills curriculum at school.

Conclusion

The study highlights the importance of increasing HIV awareness and inculcating sexual and reproductive health into the school curriculum. The study further shows the imperative need to recognize the role of traditional medicine in the health care choices of this community. Traditional value systems need to be incorporated into the way that education and health care is proposed to the community leaders, to increase acceptance and utilization of health services.

Should condoms be available in secondary schools? Discourse and policy dilemma for safeguarding adolescent reproductive and sexual health in Rwanda

Introduction

As a response to challenges associated with adolescent reproductive and sexual health, policy makers in Rwanda have instituted preventive measures against risky sexual behaviours among adolescents. There is an ongoing debate on whether condoms should be made available in secondary schools to minimise risks related to unprotected sex in the context of a growing number of unintended pregnancies among school girls. This paper aims to examine the proposal of condom provision in Rwandan secondary schools through the analysis of policy narratives and the claims-making process.

Methods

A narrative policy analysis was used to understand the claims and counter claims surrounding the debate on the provision of condoms in secondary schools. Documents that were consulted include: the national reproductive health policy, the girls' education policy, the national behaviour change and communication policy for the health sector, the Rwanda national policy on condoms, the adolescent sexual reproductive health and rights policy and the Rwanda family planning policy.

Results

Social and cultural norms in the Rwandan context consider adolescent sexual practices as immoral and thus reject the idea of providing condoms in secondary schools. However, some stakeholders promoting reproductive health suggest that ignoring that some adolescents are sexually active will prevent them from accessing appropriate reproductive and sexual health protective programmes. Consequently, adolescents will be exposed to risky sexual behaviours, a situation which may be counter productive to the overarching goal of safeguarding adolescent sexual health which might impact their long-term education goals.

Conclusion

Making condoms available in secondary schools evokes different meanings among the debaters, underscoring the complex nature of the condom provision debate in Rwanda. This paper calls for a revision of policies related to adolescent reproductive and sexual health in order to answer to the issues of risky sexual behaviours among secondary school students.

Factorial Structure and Psychometric Properties of a Brief Scale of the Condom Use Self-Efficacy for Spanish-Speaking People

BACKGROUND

Studies have shown the role played by perceived self-efficacy in explaining condom negotiation and condom use.

AIMS

The factorial structure and the psychometric properties of the Brief Condom Use Self-Efficacy Scale are presented.

METHOD

The study included 368 men and 456 women aged 17 to 55 years ( M_age = 25.01, SD = 6.93).

RESULTS

Exploratory factor analysis yielded three factors: fear of rejection, impulse control, and condom acquisition and negotiation, which together accounted for 68% of the total variance. That structure was confirmed through confirmatory factor analysis. Cronbach's alpha for the Brief Condom Use Self-Efficacy Scale was .71. The scale provided adequate convergent validity, and positive correlations were observed between self-reported condom use and self-efficacy for use of other barrier methods.

DISCUSSION

This brief instrument could be a useful and appropriate measure to assess the types of condom use self-efficacy that occur at the different moments of a sexual relationship.

Creation and validation of a scale of sexuality for adolescents: Scale of Myths about Sexuality

INTRODUCTION

In recent decades western countries have become more open about sexuality and sexual relations, and adolescents get information about these issues mainly through the internet, TV and social networks. Often such information is incomplete, wrong or even contradicts itself. What favors them to develop myths, false beliefs and/or negative attitudes about sexuality, love, equality in relationships, or Sexually Transmitted Infections. At the same time, the presence of myths favors double standards, sexism, and a negative attitude toward toward personal, partner and/or social sexuality.

OBJECTIVES

To create a scale for evaluating the permanence of myths about sexuality in adolescents, and to analyze the structural reliability and validity of this scale.

METHOD

The sample was formed by a pilot group (n=216) and a final group (n=661), both with adolescents from high schools in the province of Malaga, obtained by non-probability cluster sampling. The first 69 initial items were given to the pilot sample to determine the final questions making up the "Escala de Mitos sobre la Sexualidad".

RESULT

All final items have an item-total correlation over 0.29. A final questionnaire was obtained of 27 items, grouped into 6 components. The Cronbach's alpha coefficient indicated a high internal consistency of the test (0.881). Moreover, it confirms a significant difference between the sexes and between grades (cohorts).

CONCLUSION

The Scale has appropriate parameters for use in sex education and research. The use of this scale would help to discover adherence to the myths of adolescents, in order to eliminate them and build a solid, free and personal concept of sexuality.

Sexual health of very young adolescents in South Western Uganda: a cross-sectional assessment of sexual knowledge and behavior

BACKGROUND

In most Sub-Saharan African countries, little is known about young adolescents' sexual and reproductive health (SRH). Though some efforts have been made to understand and improve SRH of older adolescents, very young adolescents (VYAs) are often overlooked, and little is known about their sexual knowledge and behaviors. The goal of this study was to describe SRH knowledge, information-seeking, and sexual behavior of VYAs in Uganda.

METHODS

A cross-sectional survey was administered in 33 primary schools in June and July of 2016. Trained interviewers administered surveys to adolescents ages 10-14 regarding SRH knowledge, information-seeking, sexual behavior, and relevant covariates. Continuous variables were summarized as means (SD) or medians (IQR) whereas categorical variables were summarized as proportions (percentages).

RESULTS

A total of 1096 adolescents were included in this analysis, 81.8% of which were from rural areas, with a median age of 12. Regarding sexually transmitted infections (STIs) knowledge; 95% knew HIV while 37% knew other STIs apart from HIV. Although 47% knew at least one way in which HIV is acquired only 8% knew at least four ways. Regarding contraceptive knowledge, 56% mentioned at least one modern method of preventing pregnancy (condoms, pills, intrauterine devices, implants, or injections). The majority (85%) of VYAs reported accessing SRH information in the media with 35% reporting accessing media with sexual content while 10% vs 22% consulted their father or mother respectively and 31% a school source. At least 7.6% of VYAs had ever had sexual intercourse, 90% of which were not using any protection.

CONCLUSION

Comprehensive SRH knowledge was low among VYAs in this study. Media remains an important source of information for SRH for this age group though it may be misused as some adolescents reported accessing sexual content that may be inappropriate. A large proportion of sexually active VYAs reported sexual risky behaviors. This study highlights the need for an accurate and more comprehensive SRH education approach for VYAs in Uganda at an opportune age before the majority engage in sexual behavior.

Challenges to implementing national comprehensive sexuality education curricula in low- and middle-income countries: Case studies of Ghana, Kenya, Peru and Guatemala

School-based comprehensive sexuality education (CSE) can help adolescents achieve their full potential and realize their sexual and reproductive health and rights. This is particularly pressing in low- and middle-income countries (LMICs), where high rates of unintended pregnancy and STIs among adolescents can limit countries' ability to capitalize on the demographic dividend. While many LMICs have developed CSE curricula, their full implementation is often hindered by challenges around program planning and roll-out at the national and local level. A better understanding of these barriers, and similarities and differences across countries, can help devise strategies to improve implementation; yet few studies have examined these barriers. This paper analyzes the challenges to the implementation of national CSE curricula in four LMICs: Ghana, Kenya, Peru and Guatemala. It presents qualitative findings from in-depth interviews with central and local government officials, civil society representatives, and community level stakeholders ranging from religious leaders to youth representatives. Qualitative findings are complemented by quantitative results from surveys of principals, teachers who teach CSE topics, and students aged 15-17 in a representative sample of 60-80 secondary schools distributed across three regions in each country, for a total of around 3000 students per country. Challenges encountered were strikingly similar across countries. Program planning-related challenges included insufficient and piecemeal funding for CSE; lack of coordination of the various efforts by central and local government, NGOs and development partners; and inadequate systems for monitoring and evaluating teachers and students on CSE. Curriculum implementation-related challenges included inadequate weight given to CSE when integrated into other subjects, insufficient adaptation of the curriculum to local contexts, and limited stakeholder participation in curriculum development. While challenges were similar across countries, the strategies used to overcome them were different, and offer useful lessons to improve implementation for these and other low- and middle-income countries facing similar challenges.

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.

Effectiveness of population based risk reduction programs for risky sexual behavior among young people in low- and middle-income countries: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this review is to synthesize the best available evidence on the effectiveness of population based (public health) risk reduction interventions (programs and services) on sexual risk taking among young people (aged 10 to 24 years old) in low- and middle-income countries (LMICs).The specific review questions are.

[Comprehensive sexual education in Mexico: an analysis of coverage, comprehensiveness and continuity of contents in Mexican public and private schools]

Objective:

To analyze coverage of comprehensive sex education (CSE) in high schools in Mexico and describe whether it is comprehensive, homogeneous and has continuity based on student reports of exposure to topics in three dimensions: reproductive and sexual health, self-efficacy and rights and relations.

Materials and methods:

Within a probabilistic, cross-sectional survey with stratified, cluster sampling, a nationally representative sample of 3 824 adolescents attending 45 public and private high-schools in urban and rural areas completed questionnaires on CSE.

Results:

The proportion of adolescents reporting having received sex education from school personnel varies depending on topics and grade level. Topics most frequently covered are those related to sexual and reproductive health while rights and relations are least frequently dealt with. Most sex education topics are covered during junior high school and much less frequently in elementary or high school.

Conclusions:

CSE needs to be comprehensive and homogenous in terms of content, ensure inclusion of priority topics, meet national and international recommendations, ensure continuity and adapt contents to student age through all education levels.

Sexual and reproductive health outcomes are positively associated with comprehensive sexual education exposure in Mexican high-school students

Objectives

To describe the comprehensive sex education (CSE) coverage and to evaluate a set of indicators related to knowledge, attitudes, and practices associated with the seven components of the CSE framework among Mexican high-school students.

Methods

We conducted a cross-sectional survey of a nationally representative sample of students in public and private high schools in Mexico. Questions about CSE coverage and about knowledge, attitudes, and practices related to sexual health were included. We present descriptive statistics for demographic characteristics, exposure to CSE, and sexual health outcomes. We fitted a series of multivariate logistic regression models to examine the association between each CSE component exposure and sexual health outcomes, adjusting for age and sex.

Results

There were significant associations between being exposed to each CSE components and the related sexual health outcomes. The strongest one was for identifying effective contraceptives among those exposed to the Sexual and Reproductive Health component (SRH) (OR 4.10; 95%CI[2.93,5.75]). Also, students exposed to the relationships component had 20% higher odds of affirming they could convince their partner to use condoms (OR 1.20; 95%CI[1.05,1.36]).

Conclusions

This paper provides evidence of the potential beneficial effects of CSE on attitudes, knowledge, and behaviors regarding sexual and reproductive health among adolescents. In addition, it identifies areas that should be strengthened to increase the positive impact of CSE.

Evaluating Effectiveness of Abstinence Education

PURPOSE

This study examined the effectiveness of an abstinence education program that was sensitive to federally mandated curriculum and measures.

METHODS

The intervention was delivered to 5,772 middle school and high school students. Effectiveness was assessed by a measure that was anchored on A-H themes, which are components of federally mandated curricular components of abstinence education. To better understand the relationship of different variables and determine the significance of student's improvements on the A-H measure scores, the ANCOVA was used with the pretest score and age as covariates and the use of gender and ethnicity as fixed factors in the analysis.

RESULTS

While controlling for the effects of the pretest, the analyses showed that age and gender were main effects but that ethnicity did not prove to be related to the outcome scores. Results demonstrated that the effectiveness of the program decreased as adolescent boys aged. There were no significant interactions in the gender and ethnicity variables.

CONCLUSIONS

The findings of this study will be beneficial to program developers in understanding what variations and demographics are most receptive to this particular abstinence-only education model. Further studies in this area are needed to evaluate the effectiveness of currently available programs.

Non-specialist psychosocial support interventions for women living with HIV: A systematic review

Many women living with HIV experience a range of physical, social, and psychological challenges linked to their HIV status. Psychosocial support interventions may help women cope with these challenges and may allow women to make better decisions around their sexual and reproductive health (SRH), yet no reviews have summarized the evidence for the impact of such interventions on well-being and SRH decision-making among women living with HIV. We systematically reviewed the evidence for non-specialist delivered psychosocial support interventions for women living with HIV, which are particularly relevant in low-resource settings. Outcomes of interest included mental, emotional, social well-being and/or quality of life, common mental health disorders, and SRH decision-making. Searching was conducted through four electronic databases and secondary reference screening. Systematic methods were used for screening and data abstraction. Nine articles met the inclusion criteria, showing positive or mixed results for well-being and depressive symptoms indicators. No studies reported on SRH decision-making outcomes. The available evidence suggests that psychosocial support interventions may improve self-esteem, coping and social support, and reduce depression, stress, and perceived stigma. However, evidence is mixed. Most studies placed greater emphasis on instrumental health outcomes to prevent HIV transmission than on the intrinsic well-being and SRH of women living with HIV. Many interventions included women living with HIV in their design and implementation. More research is required to understand the most effective interventions, and their effect on sexual and reproductive health and rights.

HIV Knowledge and Risk among Zambian Adolescent and Younger Adolescent Girls: Challenges and Solutions

In sub-Saharan Africa, young women are at the highest risk of HIV infection. Comprehensive sexuality education (CSE) and open parent-child communication about sex have been shown mitigate risky sexual practices associated with HIV. This study aimed to identify sources of HIV prevention knowledge among young women aged 10-14 years and community-based strategies to enhance HIV prevention in Zambia. Focus group discussions were conducted with 114 young women in Zambian provinces with the highest rates (~20%) of HIV. Discussions were recorded, transcribed and coded, and addressed perceived HIV risk, knowledge and access to information. Participants reported that limited school-based sexuality education reduced the potential to gain HIV prevention knowledge, and that cultural and traditional practices promoted negative attitudes regarding condom use. Parent-child communication about sex was perceived to be limited; parents were described as feeling it improper to discuss sex with their children. Initiatives to increase comprehensive sexuality education and stimulate parental communication about sexual behavior were suggested by participants. Culturally tailored programmes aiming to increase parent-child communication appear warranted. Community-based strategies aimed at enhancing protective sexual behaviour among those most at risk are essential.

Experience with a Multinational, Secondary School Education Module with a Focus on Prevention of Virus Infections

Worldwide, virus infections are responsible for many diseases in terms of morbidity and mortality. Vaccinations and therapies are only available for relatively few virus infections and not always where they are needed. However, knowledge of transmission routes can prevent virus infection. In the context of this study, we measured the effects of a secondary school education module, named Viruskenner, on knowledge, attitude, and risk behavior as these relate to virus infections. A nonrandomized intervention study was conducted between April and August 2015 to assess the effect of this 2-month education module on knowledge, attitude, and behavior of 684 secondary school students in the Netherlands, Suriname, and Indonesia. For the Netherlands, a control group of a further 184 students was added. Factor analysis was performed on questions pertaining to attitude and behavior. Comparative analyses between pre- and posttest per country were done using multiple linear regression, independent sample T-tests, and one-way analysis of variance. These showed a significant increase in knowledge about virus infections and the prevention of infectious diseases among the Dutch and Surinamese groups, whereas a trend of increased knowledge was evident among the Indonesian participants. The Dutch control group showed an overall decrease in knowledge. Regression analyses showed that there was a significant interaction effect between participation and time on knowledge, attitude, and awareness and behavior and risk infection. Attitudes improved significantly in the intervention group. Pearson correlation coefficients between knowledge, attitude, and behavior were found to be positive.

Impact of teachers training on HIV/AIDS education program among secondary school students in Bangladesh: A cross-sectional survey

BACKGROUND

In 2007, the Government of Bangladesh incorporated a chapter on HIV/AIDS into the national curriculum for an HIV-prevention program for school students. For the efficient dissemination of knowledge, an intervention was designed to train the teachers and equip them to educate on the topic of HIV/AIDS. The present study intended to understand the impact of this intervention by assessing the knowledge, attitudes and behaviours related to HIV/AIDS, among the targeted students.

METHODS

A cross-sectional survey was conducted with the students at randomly selected schools from two adjacent districts. Considering exposure to intervention, one district was assigned for intervention and the other as a control. In total, 1,381 students, aged 13-18 years (or above) were interviewed, 675 from the control areas and 706 from the intervention areas. Univariate and bivariate analyses were performed on the collected data.

RESULTS

A significantly higher proportion (p<0.001) of students in the intervention areas attended HIV/AIDS classes, demonstrated better knowledge and fewer misconceptions regarding the transmission and prevention of HIV. The same was derived regarding their attitude towards people living with HIV, as a higher proportion (p<0.001) responded positively, compared to the control groups of the study. Additionally, multinomial logistic regression analysis showed that students in intervention area were more likely to have good knowledge on HIV transmission (OR 2.71, 95% CI 1.74-4.22) and prevention (OR 2.15, 95% CI 1.41-3.26) compared to the students in the control areas.

CONCLUSIONS

The training programme needs to be scaled up, since it is likely to have an impact among students; we have witnessed that the interventions particularly helped increase HIV/AIDS knowledge among students and positively change the students' attitudes towards HIV/AIDS.

"At our age, we would like to do things the way we want: " a qualitative study of adolescent HIV testing services in Kenya

Supplemental Digital Content is available in the text

Objectives:

Adolescents in Africa have low HIV testing rates. Better understanding of adolescent, provider, and caregiver experiences in high-burden countries such as Kenya could improve adolescent HIV testing programs.

Design:

We conducted 16 qualitative interviews with HIV-positive and HIV-negative adolescents (13–18 years) and six focus group discussions with Healthcare workers (HCWs) and caregivers of adolescents in Nairobi, Kenya.

Methods:

Semi-structured interviews and focus groups were recorded and transcribed. Analysis employed a modified constant comparative approach to triangulate findings and identify themes influencing testing experiences and practices.

Results:

All groups identified that supportive interactions during testing were essential to the adolescent's positive testing experience. HCWs were a primary source of support during testing. HCWs who acted respectful and informed helped adolescents accept results, link to care, or return for repeat testing, whereas HCWs who acted dismissive or judgmental discouraged adolescent testing. Caregivers universally supported adolescent testing, including testing with the adolescent to demonstrate support. Caregivers relied on HCWs to inform and encourage adolescents. Although peers played less significant roles during testing, all groups agreed that school-based outreach could increase peer demand and counteract stigma. All groups recognized tensions around adolescent autonomy in the absence of clear consent guidelines. Adolescents valued support people during testing but wanted autonomy over testing and disclosure decisions. HCWs felt pressured to defer consent to caregivers. Caregivers wanted to know results regardless of adolescents’ wishes.

Conclusion:

Findings indicate that strengthening HCW, caregiver, and peer capacities to support adolescents while respecting their autonomy may facilitate attaining ‘90-90-90’ targets for adolescents.

Interventions to strengthen the HIV prevention cascade: a systematic review of reviews

BACKGROUND

Much progress has been made in interventions to prevent HIV infection. However, development of evidence-informed prevention programmes that translate the efficacy of these strategies into population effect remain a challenge. In this systematic review, we map current evidence for HIV prevention against a new classification system, the HIV prevention cascade.

METHODS

We searched for systematic reviews on the effectiveness of HIV prevention interventions published in English from Jan 1, 1995, to July, 2015. From eligible reviews, we identified primary studies that assessed at least one of: HIV incidence, HIV prevalence, condom use, and uptake of HIV testing. We categorised interventions as those seeking to increase demand for HIV prevention, improve supply of HIV prevention methods, support adherence to prevention behaviours, or directly prevent HIV. For each specific intervention, we assigned a rating based on the number of randomised trials and the strength of evidence.

FINDINGS

From 88 eligible reviews, we identified 1964 primary studies, of which 292 were eligible for inclusion. Primary studies of direct prevention mechanisms showed strong evidence for the efficacy of pre-exposure prophylaxis (PrEP) and voluntary medical male circumcision. Evidence suggests that interventions to increase supply of prevention methods such as condoms or clean needles can be effective. Evidence arising from demand-side interventions and interventions to promote use of or adherence to prevention tools was less clear, with some strategies likely to be effective and others showing no effect. The quality of the evidence varied across categories.

INTERPRETATION

There is growing evidence to support a number of efficacious HIV prevention behaviours, products, and procedures. Translating this evidence into population impact will require interventions that strengthen demand for HIV prevention, supply of HIV prevention technologies, and use of and adherence to HIV prevention methods.

FUNDING

Bill & Melinda Gates Foundation.

HIV Prevention 2020: a framework for delivery and a call for action

Although effective programmes are available and several countries have seen substantial declines in new HIV infections, progress in the reduction of adult HIV incidence has been slower than expected worldwide and many countries have not had large decreases in new infections in adults despite large reductions in paediatric infections. Reasons for slow progress include inadequate commitment, investment, focus, scale, and quality of implementation of prevention and treatment interventions. The UNAIDS-Lancet Commission on Defeating AIDS-Advancing Global Health reported that the provision of large-scale, effective HIV prevention programmes has failed and called on stakeholders to "get serious about HIV prevention". An ambitious worldwide target has been set by UNAIDS to reduce new infections below 500 000 by 2020-a 75% reduction from 2010. Models show that such a reduction requires a combination of primary prevention interventions and preventative effects of treatment. Achievement of the target will require more effective delivery of HIV prevention for sufficient coverage in populations at greatest risk of infection ensuring that interventions that have proved effective are made available, barriers to their uptake are overcome, demand is created, and use is consistent and occurs at the right scale with high coverage. This paper discusses how programmatic targets for prevention in a worldwide plan could be used to re-energise the HIV prevention approach. A management framework is proposed outlining global, regional, national, and subnational actions and is summarised in a call for action on HIV prevention for 2020.

TIMING OF SEXUAL DEBUT AMONG UNMARRIED YOUTHS AGED 15–24 YEARS IN SUB-SAHARAN AFRICA

This study aimed to contribute to the evidence on the timing of sexual debut in young people in sub-Saharan African countries. Data were extracted from 34 nationally representative surveys conducted in the region between 2006 and 2014. The study sample comprised unmarried women (n=167,932) and men (n=76,900) aged 15–24 years. Descriptive techniques and Cox proportional regression models were used to estimate the timing of sexual debut, and Kaplan–Meier hazard curves were used to describe the patterns of sexual debut in each country by sex. For the countries studied, sexual debut for both women and men occurred between the ages of 15 and 18 years, with median ages of 16 for women and 17 for men. Overall, education and household wealth provided significant protection against early sexual debut among women, but the reverse was found among men for wealth. Women in rural areas, in female-headed households and in Central, South and West Africa reported higher hazards of early commencement of sexual activity than their counterparts in urban, male-headed households and East Africa. However, the impact of these variables on male sexual debut did not follow a consistent pattern. Varied timing, as well as country-specific risk factors associated with sexual debut for young women and men across sub-Saharan Africa, were identified. Sexual health programmes and interventions for young people may require different approaches for young women and men.

Can Policy Interventions Affect HIV-Related Behaviors? A Systematic Review of the Evidence from Low- and Middle-Income Countries

In their response to HIV, many countries have adopted and enacted policies to reduce transmission and increase HIV-related service use. Theoretically, policy-level interventions for HIV prevention have the potential to improve health behavior outcomes. These policy interventions vary in their scale, from relatively minor changes in clinical policy to major national legal initiatives. Assessing the effectiveness of HIV policy interventions is a challenging undertaking. While many policies exist and guide HIV programmes, relatively few have specifically been evaluated for their effects on reducing HIV risk taking or increasing HIV health-seeking behaviors. Thus, questions on the effectiveness of policy interventions to prevent HIV and change HIV-related risk behaviors remain largely unanswered. To address this current gap in the literature, we systematically reviewed the existing evidence on the effect of HIV policy interventions on changing HIV-related behaviors in low-and middle-income countries.

Impact of a Text-Messaging Program on Adolescent Reproductive Health: A Cluster-Randomized Trial in Ghana

OBJECTIVES

To evaluate whether text-messaging programs can improve reproductive health among adolescent girls in low- and middle-income countries.

METHODS

We conducted a cluster-randomized controlled trial among 756 female students aged 14 to 24 years in Accra, Ghana, in 2014. We randomized 38 schools to unidirectional intervention (n = 12), interactive intervention (n = 12), and control (n = 14). The unidirectional intervention sent participants text messages with reproductive health information. The interactive intervention engaged adolescents in text-messaging reproductive health quizzes. The primary study outcome was reproductive health knowledge at 3 and 15 months. Additional outcomes included self-reported pregnancy and sexual behavior. Analysis was by intent-to-treat.

RESULTS

From baseline to 3 months, the unidirectional intervention increased knowledge by 11 percentage points (95% confidence interval [CI] = 7, 15) and the interactive intervention by 24 percentage points (95% CI = 19, 28), from a control baseline of 26%. Although we found no changes in reproductive health outcomes overall, both unidirectional (odds ratio [OR] = 0.14; 95% CI = 0.03, 0.71) and interactive interventions (OR = 0.15; 95% CI = 0.03, 0.86) lowered odds of self-reported pregnancy for sexually active participants.

CONCLUSIONS

Text-messaging programs can lead to large improvements in reproductive health knowledge and have the potential to lower pregnancy risk for sexually active adolescent girls.

Combination HIV prevention options for young women in Africa

Although the number of new HIV infections has declined by over 30% in the past decade, the number of people who acquire HIV each year remains unacceptably high. In 2014 the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimated that there were about 2 million new HIV infections. The virus continues to spread, particularly in key populations, such as men who have sex with men (MSM), transgender individuals, sex workers and people who inject drugs. In Africa, young women have the highest HIV incidence rates. Scaling up known efficacious HIV prevention strategies for these groups at high risk is therefore a high priority. HIV prevention has generally been targeted at HIV-negative individuals or in some instances, entire communities. Prevention efforts are, however, shifting from a narrow focus on HIV-uninfected persons to a continuum of prevention that includes both HIV-negative and HIV-positive individuals. Given that a single HIV prevention intervention is unlikely to be able to alter the epidemic trajectory as HIV epidemics in communities are complex and comprise a mosaic of different risk factors and different routes of transmission, there is need to provide combination prevention. Hence, a mix of behavioural, biomedical and structural HIV prevention options is likely to be needed to alter the course of the HIV epidemic. The combination of HIV prevention interventions needed will vary depending on cultural context, the population targeted and the stage of the epidemic. This paper reviews the available HIV prevention strategies for young women and discusses new HIV prevention approaches in development.

Errors and Predictors of Confidence in Condom Use amongst Young Australians Attending a Music Festival

Objectives. To determine the confidence and ability to use condoms correctly and consistently and the predictors of confidence in young Australians attending a festival. Methods. 288 young people aged 18 to 29 attending a mixed-genre music festival completed a survey measuring demographics, self-reported confidence using condoms, ability to use condoms, and issues experienced when using condoms in the past 12 months. Results. Self-reported confidence using condoms was high (77%). Multivariate analyses showed confidence was associated with being male (P < 0.001) and having had five or more lifetime sexual partners (P = 0.038). Reading packet instructions was associated with increased condom use confidence (P = 0.011). Amongst participants who had used a condom in the last year, 37% had experienced the condom breaking and 48% had experienced the condom slipping off during intercourse and 51% when withdrawing the penis after sex. Conclusion. This population of young people are experiencing high rates of condom failures and are using them inconsistently or incorrectly, demonstrating the need to improve attitudes, behaviour, and knowledge about correct and consistent condom usage. There is a need to empower young Australians, particularly females, with knowledge and confidence in order to improve condom use self-efficacy.

School-based interventions for preventing HIV, sexually transmitted infections, and pregnancy in adolescents

BACKGROUND

School-based sexual and reproductive health programmes are widely accepted as an approach to reducing high-risk sexual behaviour among adolescents. Many studies and systematic reviews have concentrated on measuring effects on knowledge or self-reported behaviour rather than biological outcomes, such as pregnancy or prevalence of sexually transmitted infections (STIs).

OBJECTIVES

To evaluate the effects of school-based sexual and reproductive health programmes on sexually transmitted infections (such as HIV, herpes simplex virus, and syphilis), and pregnancy among adolescents.

SEARCH METHODS

We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) for published peer-reviewed journal articles; and ClinicalTrials.gov and the World Health Organization's (WHO) International Clinical Trials Registry Platform for prospective trials; AIDS Educaton and Global Information System (AEGIS) and National Library of Medicine (NLM) gateway for conference presentations; and the Centers for Disease Control and Prevention (CDC), UNAIDS, the WHO and the National Health Service (NHS) centre for Reviews and Dissemination (CRD) websites from 1990 to 7 April 2016. We handsearched the reference lists of all relevant papers.

SELECTION CRITERIA

We included randomized controlled trials (RCTs), both individually randomized and cluster-randomized, that evaluated school-based programmes aimed at improving the sexual and reproductive health of adolescents.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, evaluated risk of bias, and extracted data. When appropriate, we obtained summary measures of treatment effect through a random-effects meta-analysis and we reported them using risk ratios (RR) with 95% confidence intervals (CIs). We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included eight cluster-RCTs that enrolled 55,157 participants. Five trials were conducted in sub-Saharan Africa (Malawi, South Africa, Tanzania, Zimbabwe, and Kenya), one in Latin America (Chile), and two in Europe (England and Scotland). Sexual and reproductive health educational programmesSix trials evaluated school-based educational interventions.In these trials, the educational programmes evaluated had no demonstrable effect on the prevalence of HIV (RR 1.03, 95% CI 0.80 to 1.32, three trials; 14,163 participants; low certainty evidence), or other STIs (herpes simplex virus prevalence: RR 1.04, 95% CI 0.94 to 1.15; three trials, 17,445 participants; moderate certainty evidence; syphilis prevalence: RR 0.81, 95% CI 0.47 to 1.39; one trial, 6977 participants; low certainty evidence). There was also no apparent effect on the number of young women who were pregnant at the end of the trial (RR 0.99, 95% CI 0.84 to 1.16; three trials, 8280 participants; moderate certainty evidence). Material or monetary incentive-based programmes to promote school attendanceTwo trials evaluated incentive-based programmes to promote school attendance.In these two trials, the incentives used had no demonstrable effect on HIV prevalence (RR 1.23, 95% CI 0.51 to 2.96; two trials, 3805 participants; low certainty evidence). Compared to controls, the prevalence of herpes simplex virus infection was lower in young women receiving a monthly cash incentive to stay in school (RR 0.30, 95% CI 0.11 to 0.85), but not in young people given free school uniforms (Data not pooled, two trials, 7229 participants; very low certainty evidence). One trial evaluated the effects on syphilis and the prevalence was too low to detect or exclude effects confidently (RR 0.41, 95% CI 0.05 to 3.27; one trial, 1291 participants; very low certainty evidence). However, the number of young women who were pregnant at the end of the trial was lower among those who received incentives (RR 0.76, 95% CI 0.58 to 0.99; two trials, 4200 participants; low certainty evidence). Combined educational and incentive-based programmesThe single trial that evaluated free school uniforms also included a trial arm in which participants received both uniforms and a programme of sexual and reproductive education. In this trial arm herpes simplex virus infection was reduced (RR 0.82, 95% CI 0.68 to 0.99; one trial, 5899 participants; low certainty evidence), predominantly in young women, but no effect was detected for HIV or pregnancy (low certainty evidence).

AUTHORS' CONCLUSIONS

There is a continued need to provide health services to adolescents that include contraceptive choices and condoms and that involve them in the design of services. Schools may be a good place in which to provide these services. There is little evidence that educational curriculum-based programmes alone are effective in improving sexual and reproductive health outcomes for adolescents. Incentive-based interventions that focus on keeping young people in secondary school may reduce adolescent pregnancy but further trials are needed to confirm this.

A comprehensive review of reviews of school-based interventions to improve sexual-health

OBJECTIVE

To systematically review systematic reviews of school-based sexual-health and relationship Education (SHRE) programmes and, thereby, identify interventions and intervention components that promote reductions in risky sexual behaviour among young people.

METHODS

Electronic bibliographies were searched systematically to identify systematic reviews of school-based interventions targeting sexual-health. Results were summarised using a narrative synthesis.

RESULTS

Thirty-seven systematic reviews (summarising 224 primary randomised controlled trials) met our inclusion and quality assessment criteria. In general, these reviews analysed distinct sets of primary studies, and no comprehensive review of available primary studies was identified. Interventions were categorised into five types that segment this review literature. Unfortunately, many reviews reported weak and inconsistent evidence of behaviour change. Nonetheless, integration of review findings generated a list of 32 design, content and implementation characteristics that may enhance effectiveness of school-based, sexual-health interventions. Abstinence-only interventions were found to be ineffective in promoting positive changes in sexual behaviour. By contrast, comprehensive interventions, those specifically targeting HIV prevention, and school-based clinics were found to be effective in improving knowledge and changing attitudes, behaviours and health-relevant outcomes.

CONCLUSIONS

School-based interventions targeting risky sexual behaviour can be effective. Particular design, content and implementation characteristics appear to be associated with greater effectiveness. We recommend consideration of these characteristics by designers of school-based sexual-health interventions.

School-based sexual health education interventions to prevent STI/HIV in sub-Saharan Africa: a systematic review and meta-analysis

Background

School-based sexual health education has the potential to provide an inclusive and comprehensive approach to promoting sexual health among young people. We reviewed evaluations of school-based sexual health education interventions in sub-Saharan Africa to assess effectiveness in reducing sexually transmitted infections and promoting condom use.

Methods

We searched ten electronic databases, hand-searched key journals, and reference lists of included articles for potential studies. Data were extracted on outcomes, intervention characteristics, methods and study characteristics indicative of methodological quality. Where possible, data were synthesized using random effect meta-analysis. Intervention features found predominantly in effective interventions were noted.

Results

The initial search retrieved 21634 potentially relevant citations. Of these, 51 papers reporting on 31 interventions were included. No evaluation reported statistically significant effects on the incidence or prevalence of Human Immunodeficiency Virus and Herpes Simplex Virus 2 infections. However, intervention participants reported statistically significant greater condom use in both randomised controlled trials and non-randomised trials for short (less than 6 months) follow-up periods (OR = 1.62, 95 % CI = 1.03–2.55 and OR = 2.88, 95 % CI = 1.41–5.90 respectively). For intermediate (6–10 months) and long-term (more than 10 months) follow-up periods, the effect was statistically significant (OR = 1.40, 95 % CI = 1.16–1.68) and marginally significant (OR = 1.22, 95 % CI = 0.99–1.50) among the randomised trials respectively. Only 12 of the 31 interventions reported implementation details, out of which seven reported on fidelity.

Conclusion

School-based sexual health education has the potential to promote condom use among young people in sub-Saharan Africa. However, further work is needed to develop and evaluate interventions that have measurable effects on sexually transmitted infections.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3715-4) contains supplementary material, which is available to authorized users.

Correlates of Sexually Transmitted Infections among Adolescents Attending Public High Schools, Panama, 2015

BACKGROUND

Sexually transmitted infections (STIs) are common in adolescents worldwide. Vulnerability to STIs increases with risky sexual practices. This study described the sexual practices, estimated the prevalence of STIs, and identified correlates associated with STIs among participants, enrolled in public high schools, in the District of Panama, Panama.

METHODS

A cross sectional study, using multistage cluster sampling, was conducted among participants, aged 14-18 years, enrolled in public high schools, in the District of Panama, Panama City, Panama, from August to November, 2015. Participants completed a self-administered questionnaire and provided biological samples. The samples of those reporting sexual activity (oral, vaginal, and/or anal intercourse) were tested for STIs. Odds ratios were used to identify correlates of STIs in this population.

RESULTS

A total of 592 participants were included, of whom, 60.8% reported a history of sexual activity, and 24.4% tested positive for least one STI. STIs were more common in female participants, (33.5%). Compared to those without STIs, higher proportions of those with at least one STI reported ≥3 sexual partners in their lifetime (60.0%) and current sexual activity (76.3%). In the multivariable model, correlates of STI included female participants (Adjusted Odds Ratio (AOR) = 5.8, 95% Confidence Interval (CI) 2.3-14.6) and those who engaged in sexual intercourse with casual partners (AOR = 3.0, 95% CI: 1.2-7.5).

CONCLUSIONS

We report a high STI prevalence among adolescents attending public high schools, in the District of Panama. Reported risky sexual practices were common and correlated with STIs. Female participants and those reporting sexual intercourse with casual partners were more likely test positive for at least one STI. Our study identified a need for effective interventions to curb future infections in this population.

School-based interventions for improving contraceptive use in adolescents

BACKGROUND

Young women, especially adolescents, often lack access to modern contraception. Reasons vary by geography and regional politics and culture. The projected 2015 birth rate in 'developing' regions was 56 per 1000 compared with 17 per 1000 for 'developed' regions.

OBJECTIVES

To identify school-based interventions that improved contraceptive use among adolescents

SEARCH METHODS

Until 6 June 2016, we searched for eligible trials in PubMed, CENTRAL, ERIC, Web of Science, POPLINE, ClinicalTrials.gov and ICTRP.

SELECTION CRITERIA

We considered randomized controlled trials (RCTs) that assigned individuals or clusters. The majority of participants must have been 19 years old or younger.The educational strategy must have occurred primarily in a middle school or high school. The intervention had to emphasize one or more effective methods of contraception. Our primary outcomes were pregnancy and contraceptive use.

DATA COLLECTION AND ANALYSIS

We assessed titles and abstracts identified during the searches. One author extracted and entered the data into RevMan; a second author verified accuracy. We examined studies for methodological quality.For unadjusted dichotomous outcomes, we calculated the Mantel-Haenszel odds ratio (OR) with 95% confidence interval (CI). For cluster randomized trials, we used adjusted measures, e.g. OR, risk ratio, or difference in proportions. For continuous outcomes, we used the adjusted mean difference (MD) or other measures from the models. We did not conduct meta-analysis due to varied interventions and outcome measures.

MAIN RESULTS

The 11 trials included 10 cluster RCTs and an individually randomized trial. The cluster RCTs had sample sizes from 816 to 10,954; the median number of clusters was 24. Most trials were conducted in the USA and UK; one was from Mexico and one from South Africa.We focus here on the trials with moderate quality evidence and an intervention effect. Three addressed preventing pregnancy and HIV/STI through interactive sessions. One trial provided a multifaceted two-year program. Immediately after year one and 12 months after year two, the intervention group was more likely than the standard-curriculum group to report using effective contraception during last sex (reported adjusted ORs 1.62 ± standard error (SE) 0.22) and 1.76 ± SE 0.29), condom use during last sex (reported adjusted ORs 1.91 ± SE 0.27 and 1.68 ± SE 0.25), and less frequent sex without a condom in the past three months (reported ratios of adjusted means 0.50 ± SE 0.31 and 0.63 ± SE 0.23). Another trial compared multifaceted two-year programs on sexual risk reduction and risk avoidance (abstinence-focused) versus usual health education. At 3 months, the risk reduction group was less likely than the usual-education group to report no condom use at last intercourse (reported adjusted OR 0.67, 95% CI 0.47 to 0.96) and sex without a condom in the last three months (reported adjusted OR 0.59, 95% CI 0.36 to 0.95). At 3 and after 15 months, the risk avoidance group was also less likely than the usual-education group to report no condom use at last intercourse (reported adjusted ORs 0.70, 95% CI 0.52 to 0.93; and 0.61, 95% CI 0.45 to 0.85). At the same time points, the risk reduction group had a higher score than the usual-education group for condom knowledge. The third trial provided a peer-led program with eight interactive sessions. At 17 months, the intervention group was less likely than the teacher-led group to report oral contraceptive use during last sex (OR 0.57, 95% CI 0.36 to 0.91). This difference may not have been significant if the investigators had adjusted for the clustering. At 5 and 17 months, the peer-led group had a greater mean increase in knowledge of HIV and pregnancy prevention compared with the control group. An additional trial showed an effect on knowledge only. The group with an emergency contraception (EC) session was more likely than the group without the EC unit to know the time limits for using hormonal EC (pill) and the non-hormonal IUD as EC.

AUTHORS' CONCLUSIONS

Since most trials addressed preventing STI/HIV and pregnancy, they emphasized condom use. However, several studies covered a range of contraceptive methods. The overall quality of evidence was low. Main reasons for downgrading the evidence were having limited information on intervention fidelity, analyzing a subsample rather than all those randomized, and having high losses.

Internet-based educational intervention to prevent risky sexual behaviors in Mexican adolescents: study protocol

BACKGROUND

Risky sexual behaviors of adolescents in Mexico are a public health problem; 33.4 % of adolescent girls and 14.7 % of boys report not having used any protection at their first intercourse. The fertility rate is 77 births/1000 girls aged 15-19 years. The infrequent contact of adolescents with health services and the limited extent of school sex and reproductive health education require the support of innovative strategies. The objective of this paper is to present the design of an internet-based educational strategy to prevent risky sexual behaviors in Mexican adolescents.

METHODS

A field trial with intervention and comparison group and with ex-ante and ex-post measurements will be conducted in two public secondary schools. Adolescents between 14 and 15 years of age will participate. The intervention will be conducted in one school and the second school will serve as a comparison group where the investigators will observe the usual sex education provided by the school. The intervention will be delivered using an internet web page that includes four educational sessions provided during a 4 week period. Follow-up will last 3 months. Information on the study variables will be obtained through an Internet-based self-applied questionnaire and collected on three occasions: 1) when the adolescents enter the study (baseline), 2) once the intervention is completed (at 1 month) and 3) after 3 months of follow-up (at the fourth month). There will be three outcome variables: 1) knowledge in regard to sexually transmitted infections, 2) attitudes regarding condom use, and 3) self-efficacy toward consistent condom use. The generalized linear model will be used to assess changes in each outcome variable controlling for baseline measures and for study covariates.

DISCUSSION

The design and evaluation of an Internet-based educational strategy to prevent risky sexual behaviors in Mexican adolescents is important in order to provide a new, large-scale, easily implemented preventive tool.

TRIAL REGISTRATION

The study was registered at the ClinicalTrials.gov ID: NCT02686736 .

Behavioral Interventions for Preventing Sexually Transmitted Infections and Unintended Pregnancies: An Overview of Systematic Reviews

BACKGROUND

Countless sex education programs have been implemented worldwide in recent decades, but epidemiological data show no improvement in rates of sexually transmitted infections or unintended pregnancies.

OBJECTIVE

To summarize the evidence from higher-quality systematic reviews on the efficacy of behavioral interventions for the prevention of sexually transmitted infections and unintended pregnancies.

METHODS

We conducted an overview of reviews by selecting systematic reviews that met minimum quality criteria in terms of the design of the studies reviewed. We compared the results obtained when the effects of interventions were assessed on the basis of objective criteria (biological data) to those obtained when outcomes were assessed on the basis of subjective criteria (self-reports). The results of Cochrane and non-Cochrane reviews were also compared.

RESULTS

We identified 55 systematic reviews. No overall effect on the sexual behavior of program participants was observed in 72.5% of the reviews that used objective criteria and in 48.1% of the reviews based on subjective criteria. In the Cochrane reviews, no evidence of an overall effect was observed in 86% of reviews based on objective variables and in 70.5% of those based on subjective variables.

CONCLUSIONS

There is no evidence that behavioral interventions modify rates of sexually transmitted infections (including human immunodeficiency virus infections) or unintended pregnancies, particularly when effects are assessed using objective, biological data. Primary prevention strategies for sexually transmitted infections and unintended pregnancies need to be re-evaluated.