HIV, Other STIs, and Teen Pregnancy: Group-Based Comprehensive Risk Reduction Interventions for Adolescents
Summary of CPSTF Finding
- Reducing a number of self-reported risk behaviors, including:
- Engagement in any sexual activity
- Frequency of sexual activity
- Number of partners, and
- Frequency of unprotected sexual activity
- Increasing the self-reported use of protection against pregnancy and STIs
- Reducing the incidence of self-reported or clinically-documented sexually transmitted infections
There is limited direct evidence of effectiveness, however, for reducing pregnancy and HIV.
- Suggest a hierarchy of recommended behaviors that identifies abstinence as the best, or preferred method but also provides information about sexual risk reduction strategies
- Promote abstinence and sexual risk reduction without placing one approach above another
- Promote sexual risk reduction strategies, primarily or solely
This review evaluated CRR interventions delivered in school or community settings to groups of adolescents (10 19 years old). These interventions may also include other components such as condom distribution and STI testing.
CPSTF Finding and Rationale Statement
- Abstinence Education and Comprehensive Risk Reduction for Teens
Developed by The Community Guide
About The Systematic Review
Summary of Results
- 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.
Summary of Economic Evidence
- 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.
- 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
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 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
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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.
Summary Evidence Table
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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
Portions of the search terms below in parentheses indicate allowances for variation of a keyword, such as the singular and plural versions.
- (1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9)
- Human Immunodeficiency Virus
- Acquired Immunodeficiency Syndrome or AIDS
- Sexually Transmitted Diseases
- (11 or 12 or 13 or 14 or 15 or 16 or 17 and prevent(ion/ing)
- Sex(ual) Behavior(s)
- (Sex(ual)) Risk(y) Behavior(s)
- Sex(ual) Risk Reduction
- Sex(ual) Risk Taking
- Sex(ual) Risk Avoidance
- Teen/adolescent/teenage pregnancy
- Unwanted pregnancy
- Unintended pregnancy
- Postpon(ing) sex/intercourse
- Delay(ing) sex/intercourse
- Sexual Activity
- Sexual Acts
- Protected Sex
- Sexual Involvement
- Repeated Childbearing
- Repeat Pregnancies
- Fertility Control
- (18 through 39OR’d together)
- Program evaluation
- Outcome stud(ies)
- Primary Prevention
- Impact stu(dies)
- Follow-up stud(ies)
- (41through 54OR’d together)
- 10 and 40 and 55
Finally, to focus the search results to US-based studies, the following search terms/geographic locations were EXCLUDED:
- Atlantic Islands
- Caribbean Region
- Central Region
- Central America
- Indian Ocean Islands
- Latin America
- 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.
Considerations for Implementation
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