HIV, Other STIs, and Teen Pregnancy: Group-Based Comprehensive Risk Reduction Interventions for Adolescents

The CPSTF finding is based on evidence from a systematic review of 62 studies with 83 study arms (search period 1988 – August 2007). The systematic review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to preventing HIV, other STIs, and teen pregnancy.

Sixty-two studies with 83 study arms qualified for this review.

• Results from meta-analyses show that effects were favorable and statistically significant for the following outcomes.
  • Sexual activity: decrease of approximately 12% (54 study arms)
  • Frequency of sexual activity: odds ratio (OR) = 0.81, 95% confidence interval (CI) 0.72, 0.90 (14 study arms)
  • Number of partners: decrease of approximately 14% (OR = 0.83, 95% CI 0.74, 0.93; 27 study arms)
  • Unprotected sexual activity: decrease of approximately 25% (OR = 0.70, 95% CI 0.60, 0.82; 28 study arms)
  • STIs: decrease of approximately 31% (OR = 0.65, 95% CI 0.47, 0.90; 8 study arms)
  • Use of protection (including use of condoms, oral contraceptives or both): increase of approximately 13% (OR = 1.39, 95% CI 1.19, 1.62; 50 study arms)
    • Condom use: increase of approximately 12% (OR = 1.45, 95% CI 1.20, 1.74; 44 study arms)
• Results from meta-analyses were also favorable but statistically nonsignificant for the following outcomes.
  • Oral contraceptives: increase of approximately 22% (OR=1.29, 95% CI 0.89, 1.85; 10 study arms)
  • Dual use (use of both condoms and oral contraceptives): increase of approximately 17% (OR=1.21, 95% CI 0.70, 2.12; 4 study arms)
  • Pregnancy: decrease of approximately 11% (OR=0.88, 95% CI 0.60, 1.30; 11 study arms)
• The review team also examined consistent condom use, a subgroup of the condom use outcome. The results were in the favorable direction, though statistically nonsignificant.
  • Consistent condom use: OR=1.24, 95% CI 0.96, 1.62 (19 study arms)
• In 17 of the studies, at least one relevant outcome was reported that could not be included in the meta-analyses because of too little information to calculate an odds ratio. The results for these studies were consistent with the results of the meta-analyses.
• Interventions may be somewhat more effective for boys than girls.

Ten studies qualified for the economic review, including 8 economic evaluations of individual programs. Monetary values are reported in 2008 U.S. dollars.

• Program costs ranged from $66 to $10,024 per person per year (6 studies).
  • The wide range in costs is the result of variation in program content, number of participants, program duration, and type of program setting.
  • The highest cost programs tended to be multifaceted youth development interventions.
  • The lowest cost programs were school-based and curriculum-based education or involved a large number of participants.
• The benefit over cost ratio ranged from 2.7 to 3.7. This means that every dollar invested in the CRR programs yielded between $2.70-$3.70 in returns based on savings in healthcare costs related to pregnancies, HIV, and STIs and improvement in income associated with higher educational attainment (2 cost-benefit studies).
  • A separate cost-benefit study that looked at the most expensive program found that the cost of the program exceeded the economic benefits of pregnancy prevention.
• The net cost per quality adjusted life year (QALY) ranged from $9,000 to $76,000 (2 cost-utility studies).
• CRR interventions resulted in healthcare savings from prevented pregnancies and STIs that ranged from $5.80 per participant per year for those aged 13-14 years to $338 per participant per year for those aged 18-19 years (1 dissertation).
  • Avoided pregnancies made up 80% of these savings for those aged 13-14 years and more than 95% for those aged 18-19 years.
• Only 1 of 7 pregnancy prevention programs was found to be cost saving in the state of Washington. This is based on a review of programs requested by the state legislature.

Results suggest that CRR interventions are applicable to:

• Youth ranging from 10-19 years of age
• Male only, female only and coed groups
• Majority African-American, majority White, majority Hispanic and mixed race samples
• Both virgin and nonvirgin populations
• School and community settings

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

The following outlines evidence gaps for these group-based behavioral interventions to prevent or reduce the risk of adolescent pregnancy, HIV or other STIs: comprehensive risk reduction, and abstinence education interventions.

Across both reviews, there was no consistent evidence of differential effects on outcomes for any of the 12 critical moderator variables (gender, virginity status, age, race/ethnicity, setting, dosage, focus, deliverer, multicomponent, targeting, study design, and comparison group type). Also, the majority of the studies examined interventions delivered to coed groups and results were not reported by gender. This limits the ability to determine differential effectiveness by gender for comprehensive risk-reduction and abstinence education interventions. This limitation extends to the evaluation of the effectiveness of parental participation as well, since it was an uncommon component in these reviews and often had low participation rates.

More consistent reporting of moderator variables by study authors is needed to clarify which of these (or other characteristics) may maximize the effectiveness of adolescent sexual behavior interventions. In addition, common measures of sexual behavior and standard intervals for follow-up assessments of these outcomes would allow for more comparability across studies and lead to a better determination of the overall public health impact of these interventions.

In terms of economic efficiency, future research is needed to examine how cost benefit or cost-effectiveness estimates vary depending on age, gender, and risk status of participants. For programs with objectives beyond pregnancy and STI prevention, future research needs to evaluate the full impact of such programs from a societal perspective, including non-health outcomes such as improved employment potential, and higher future earnings of program participants. Finally, for school-based programs, additional research needs to address the impact on school resources where the facilities, staff, or time from the school systems may be used for these programs.

Interventions that evaluated STIs were mostly implemented in community settings with adolescents at high-risk for STIs.

Interventions included in this review were:

• Targeted to adolescents
  • Girls only
  • Boys only
  • Girls and boys together
• Delivered in group settings in schools or communities
• Led by adult or peer educators
• Implemented as single or multicomponent programs
• Tailored to groups or individuals

Content of these interventions addressed prevention of:

• HIV and STIs
• Pregnancy

Chin HB, Sipe TA, Elder RW, et al. The effectiveness of group-based comprehensive risk-reduction and abstinence education interventions to prevent or reduce the risk of adolescent pregnancy, HIV, and sexually transmitted infections: two systematic reviews for the Guide to Community Prevent. American Journal of Preventive Medicine. 2012;42(3):272-94.

Community Preventive Services Task Force. Recommendations for group-based behavioral interventions to prevent adolescent pregnancy, Human Immunodeficiency Virus, and other sexually transmitted infections: comprehensive risk reduction and abstinence education. American Journal of Preventive Medicine. 2012;42(3):304-7.

Sipe TA, Chin HB, Elder RW, Mercer SL, Chattopadhyay SK, Jacob V, Community Preventive Services Task Force. Methods for conducting Community Guide systematic reviews of evidence on effectiveness and economic efficiency of group-based behavioral interventions to prevent adolescent pregnancy, Human Immunodeficiency Virus, and other sexually transmitted infections. American Journal of Preventive Medicine. 2012;42(3):295-303.

Barbot O. Getting our heads out of the sand: using evidence to make systemwide changes. American Journal of Preventive Medicine. 2012;42(3):311-12.

Weed SE. Sex education programs for schools still in question: a commentary on meta-analysis. American Journal of Preventive Medicine. 2012;42(3):313-15.

Wiley DC. Using science to improve the sexual health of America’s youth. American Journal of Preventive Medicine. 2012;42(3):308-10.

Effectiveness Review

Analytic Framework see Figure 1 on page 276

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Effectiveness Review

Summary Evidence Table Effectiveness Review

Economic Review

Summary Evidence Table Economic Review see Table 4 on page 282

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

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Jemmott JB, III, Jemmott LS, Fong GT, McCaffree K. Reducing HIV risk-associated sexual behavior among African American adolescents: Testing the generality of intervention effects.American Journal of Community Psychology 1999;27(2):161-87.

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Moberg D, Piper DL. The Healthy for Life Project: Sexual risk behavior outcomes. AIDS Education and Prevention 1998;10(2):128-48.

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Morrison DM, Hoppe MJ, Wells EA et al. Replicating a teen HIV/STD preventive intervention in a multicultural city. AIDS Educ Prev 2007;19(3):258-73.

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Paine-Andrews A, Harris KJ, Fisher JL et al. Effects of a replication of a multicomponent model for preventing adolescent pregnancy in three Kansas communities. Fam Plann Perspect 1999;31(4):182-9.

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Philliber S, Kaye JW, Herrling S, West E. Preventing pregnancy and improving health care access among teenagers: an evaluation of the children’s aid society-carrera program.Perspect Sex Reprod Health 2002;34(5):244-51.

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Rotheram-Borus MJ, Gwadz M, Fernandez MI, Srinivasan S. Timing of HIV interventions on reductions in sexual risk among adolescents. Am J Community Psychol 1998;26(1):73-96.

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Economic Review

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Philliber S, Kaye JW, Herrling S, West E. Preventing pregnancy and improving health care access among teenagers: an evaluation of the Children’s Aid Society-Carrera Program. Perspect Sex Reprod Health 2002;34(5):244 51.

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Implementation Resources

Teen Pregnancy Prevention Evidence Review
The U.S. Department of Health and Human Services sponsors systematic reviews of the teen pregnancy prevention research literature to identify programs with evidence of effectiveness in reducing teen pregnancy, sexually transmitted infections and HIV, and associated sexual risk behaviors. Identified programs reflect a variety of approaches in the field.

The following outlines the search strategy for these group-based behavioral interventions to prevent or reduce the risk of adolescent pregnancy, HIV, or other STIs: comprehensive risk reduction, and abstinence education interventions.

With the assistance of a CDC librarian, the team searched for published studies in the following databases: CINAHL, MEDLINE, PsycINFO, PubMed, Sociological Abstracts, Web of Science, ERIC, POPLINE, NTIS, EPO, CRISP, and the online Cochrane Controlled Trials Register. In addition, we also reviewed references listed in all retrieved articles, published and unpublished reports provided by team members and elsewhere, and references from a search of an electronic database continuously updated and maintained by Prevention Research Synthesis (PRS) in the Division of HIV and AIDS Prevention at CDC.

The teams considered studies for inclusion if they were:

• Published between 1988 and 2007
• Published in English
• Studies conducted in the United States

Keywords:

Portions of the search terms below in parentheses indicate allowances for variation of a keyword, such as the singular and plural versions.

1. Adolescent(s)
2. Teenager(s)
3. Teen(s)
4. Youth
5. Young
6. Student(s)
7. School
8. College
9. Undergraduate
10. (1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9)
11. Human Immunodeficiency Virus
12. HIV
13. Acquired Immunodeficiency Syndrome or AIDS
14. AIDS
15. Sexually Transmitted Diseases
16. STD
17. STI
18. (11 or 12 or 13 or 14 or 15 or 16 or 17 and prevent(ion/ing)
19. Sex(ual) Behavior(s)
20. (Sex(ual)) Risk(y) Behavior(s)
21. Sex(ual) Risk Reduction
22. Sex(ual) Risk Taking
23. Sex(ual) Risk Avoidance
24. Teen/adolescent/teenage pregnancy
25. Unwanted pregnancy
26. Unintended pregnancy
27. Abstinence
28. Postpon(ing) sex/intercourse
29. Delay(ing) sex/intercourse
30. Sexual Activity
31. Sexual Acts
32. Protected Sex
33. Sexual Involvement
34. Repeated Childbearing
35. Repeat Pregnancies
36. Parenting
37. Cohabitation
38. Mothers
39. Fertility Control
40. (18 through 39OR’d together)
41. Program evaluation
42. Outcome stud(ies)
43. Primary Prevention
44. Impact stu(dies)
45. Follow-up stud(ies)
46. Intervention
47. Education
48. Preventive/ion
49. Evaluation/ing
50. Program
51. Promotion
52. Outcome(s)
53. Initiative
54. Design
55. (41through 54OR’d together)
56. 10 and 40 and 55

Excluded Terms

Finally, to focus the search results to US-based studies, the following search terms/geographic locations were EXCLUDED:

• Africa
• Atlantic Islands
• Australia
• Britain/ish
• Canada
• Canad(ian)
• Caribbean Region
• Central Region
• Central America
• England
• Europe
• Greenland
• Indian Ocean Islands
• Latin America
• Mexico
• Oceania
• Pacific Islands (not Hawaii)
• South America

Note: This strategy was used rather than the INCLUSION of US-based studies because not all US-based studies are explicitly indexed as such; some allow for the assumption of a US-based study unless otherwise indicated.

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.

Barriers to intervention implementation can be organized into three categories:

• Restrictions on intervention activities (e.g., community demands about intervention content)
• Funding requirements (e.g., federal requirements associated with federal funding)
• Participation challenges (e.g., low involvement from parents or adolescents, especially in voluntary programs)

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• • Reduce pregnancies in adolescents — FP-03
  • Increase the proportion of adolescents who have never had sex — FP-04
  • Increase the proportion of adolescent females who used effective birth control the last time they had sex — FP-05
  • Increase the proportion of adolescent males who used a condom the last time they had sex — FP-06
  • Increase the proportion of adolescents who use birth control the first time they have sex — FP-07
  • Increase the proportion of adolescents who get formal sex education before age 18 years — FP-08
  • Increase the proportion of adolescent females at risk for unintended pregnancy who use effective birth control — FP-11
  • Reduce the number of new HIV infections — HIV-01
  • Reduce gonorrhea rates in male adolescents and young men — STI-02
  • Reduce the proportion of adolescents and young adults with genital herpes — STI-06