School Based Sex Education and HIV Prevention in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

Abstract

ObjectivesSchool-based sex education is a cornerstone of HIV prevention for adolescents who continue to bear a disproportionally high HIV burden globally. We systematically reviewed and meta-analyzed the existing evidence for school-based sex education interventions in low- and middle-income countries to determine the efficacy of these interventions in changing HIV-related knowledge and risk behaviors.MethodsWe searched five electronic databases, PubMed, Embase, PsycInfo, CINAHL, and Sociological Abstracts, for eligible articles. We also conducted hand-searching of key journals and secondary reference searching of included articles to identify potential studies. Intervention effects were synthesized through random effects meta-analysis for five outcomes: HIV knowledge, self-efficacy, sexual debut, condom use, and number of sexual partners.ResultsOf 6191 unique citations initially identified, 64 studies in 63 articles were included in the review. Nine interventions either focused exclusively on abstinence (abstinence-only) or emphasized abstinence (abstinence-plus), whereas the remaining 55 interventions provided comprehensive sex education. Thirty-three studies were able to be meta-analyzed across five HIV-related outcomes. Results from meta-analysis demonstrate that school-based sex education is an effective strategy for reducing HIV-related risk. Students who received school-based sex education interventions had significantly greater HIV knowledge (Hedges g = 0.63, 95% Confidence Interval (CI): 0.49–0.78, p<0.001), self-efficacy related to refusing sex or condom use (Hedges g = 0.25, 95% CI: 0.14–0.36, p<0.001), condom use (OR = 1.34, 95% CI: 1.18–1.52, p<0.001), fewer sexual partners (OR = 0.75, 95% CI:0.67–0.84, p<0.001) and less initiation of first sex during follow-up (OR = 0.66, 95% CI: 0.54–0.83, p<0.001).ConclusionsThe paucity of abstinence-only or abstinence-plus interventions identified during the review made comparisons between the predominant comprehensive and less common abstinence-focused programs difficult. Comprehensive school-based sex education interventions adapted from effective programs and those involving a range of school-based and community-based components had the largest impact on changing HIV-related behaviors.

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

“…Although our results suggest high school sex education does not improve condom use confidence, overseas literature supports its efficacy. A meta-analysis comparing students participating or not participating in school-based sex education showed those who received education had significantly greater self-efficacy relating to condom use, more frequent condom use, and fewer sexual partners ( P < 0.001) [29]. Contrary to the findings of our study, the result of this meta-analysis suggests that condom efficacy can be improved independently of sexual experience, which is promising for high school educational intervention.…”

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

“…[29][30][31][32] However, poor implementation of schoolbased programs at scale, including problems of curricula lacking basic information on condoms and contraception, poor teaching, and short program durations, have often resulted in a lack of fidelity to the designed intervention, reducing program effectiveness. 33 Our study supports the idea that text-messaging programs may be effective ways to fill this gap, by providing accurate and complete information via a medium with which adolescents are comfortable.…”

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

“…There have been a large number of systematic reviews that evaluated the effectiveness of these programmes (Chin 2012; Dick 2006; DiClemente 2008; Flisher 2008; Gallant 2004; Harrison 2010; Johnson 2003; Johnson, 2011; Kim 2008; Kirby 2007; Lazarus 2010; Magnussen 2004; Medley 2009; Michielsen 2010; Paul 2008; Shepherd 2010; Yankah 2008), including reviews that have focused solely on school-based interventions (Bennet 2005; Fonner 2014; Kirby 2006; Lopez 2016; Paul 2008), and a review of reviews (Mavedzenge 2013). Many of these reviews have suggested that school- and community-based prevention programmes for adolescents have been effective in delaying self-reported sexual activity, HIV-related preventative behaviours, adolescent pregnancy, and STIs (Chin 2012; Fonner 2014; Johnson 2003; Johnson, 2011; Kirby 2009; Laud 2016), although others have reported less, or mixed, success (Bennet 2005; DiCenso 2002; Lopez 2016 Oringanje 2016). The logic model for how these programmes might be thought to influence sexual and reproductive health outcomes can be seen in Figure 1.…”