Intervention Review

Abstinence-only programs for HIV infection prevention in high-income countries

  1. Kristen Underhill2,
  2. Don Operario1,*,
  3. Paul Montgomery3

Editorial Group: Cochrane HIV/AIDS Group

Published Online: 17 OCT 2007

Assessed as up-to-date: 21 AUG 2007

DOI: 10.1002/14651858.CD005421.pub2

How to Cite

Underhill K, Operario D, Montgomery P. Abstinence-only programs for HIV infection prevention in high-income countries. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD005421. DOI: 10.1002/14651858.CD005421.pub2.

Author Information

  1. 1

    University of Oxford, Department of Social Policy and Social Work, Oxford, UK

  2. 2

    Yale Law School, New Haven, CT, USA

  3. 3

    University of Oxford, The Centre for Evidence-Based Intervention, Oxford, UK

*Don Operario, Department of Social Policy and Social Work, University of Oxford, Oxford, UK.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 17 OCT 2007




  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要


Abstinence-only interventions promote sexual abstinence as the only means of preventing sexual acquisition of HIV; they do not promote safer-sex strategies (e.g., condom use). Although abstinence-only programs are widespread, there has been no internationally focused review of their effectiveness for HIV prevention in high-income countries.


To assess the effects of abstinence-only programs for HIV prevention in high-income countries.

Search methods

We searched 30 electronic databases (e.g., CENTRAL, PubMed, EMBASE, AIDSLINE, PsycINFO) ending February 2007. Cross-referencing, handsearching, and contacting experts yielded additional citations through April 2007.

Selection criteria

We included randomized and quasi-randomized controlled trials evaluating abstinence-only interventions in high-income countries (defined by the World Bank). Interventions were any efforts to encourage sexual abstinence for HIV prevention; programs that also promoted safer-sex strategies were excluded. Results were biological and behavioral outcomes.

Data collection and analysis

Three reviewers independently appraised 20,070 records and 326 full-text papers for inclusion and methodological quality; 13 evaluations were included. Due to heterogeneity and data unavailability, we presented the results of individual studies instead of conducting a meta-analysis.

Main results

Studies involved 15,940 United States youth; participants were ethnically diverse. Seven programs were school-based, two were community-based, and one was delivered in family homes. Median final follow-up occurred 17 months after baseline.

Results showed no indications that abstinence-only programs can reduce HIV risk as indicated by self-reported biological and behavioral outcomes. Compared to various controls, the evaluated programs consistently did not affect incidence of unprotected vaginal sex, frequency of vaginal sex, number of partners, sexual initiation, or condom use.

One study found a significantly protective effect for incidence of recent vaginal sex (n=839), but this was limited to short-term follow-up, countered by measurement error, and offset by six studies with non-significant results (n=2615).

One study found significantly harmful effects for STI incidence (n=2711), pregnancy incidence (n=1548), and frequency of vaginal sex (n=338); these effects were also offset by studies with non-significant findings.

Methodological strengths included large samples, efforts to improve self-report, and analyses controlling for baseline values. Weaknesses included underutilization of relevant outcomes, underreporting of key data, self-report bias, and analyses neglecting attrition and clustered randomization.

Authors' conclusions

Evidence does not indicate that abstinence-only interventions effectively decrease or exacerbate HIV risk among participants in high-income countries; trials suggest that the programs are ineffective, but generalizability may be limited to US youth. Should funding continue, additional resources could support rigorous evaluations with behavioral or biological outcomes. More trials comparing abstinence-only and abstinence-plus interventions are needed.


Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Abstinence-only programs for preventing HIV infection in high-income countries (as defined by the World Bank)

Abstinence-only programs are widespread and well-funded, particularly in the United States and countries supported by the US President's Emergency Plan for AIDS Relief. On the premise that sexual abstinence is the best and only way to prevent HIV, abstinence-only interventions aim to prevent, stop, or decrease sexual activity. These programs differ from abstinence-plus designs: abstinence-plus programs promote safer-sex strategies (e.g., condom use) along with sexual abstinence, but abstinence-only programs do not, and instead often highlight the limitations of condom use. An up-to-date review suggests that abstinence-only programs do not affect HIV risk in low-income countries; this review examined the evidence in high-income countries.

This review included thirteen randomized controlled trials comparing abstinence-only programs to various control groups (e.g., "usual care," no intervention). Although we conducted an extensive international search for trials, all included studies enrolled youth in the US (total baseline enrollment=15,940 participants). Programs were conducted in schools, community centers, and family homes; all were delivered in family units or groups of young people. We could not conduct a meta-analysis because of missing data and variation in program designs. However, findings from the individual trials were remarkably consistent.

Overall, the trials did not indicate that abstinence-only programs can reduce HIV risk as indicated by behavioral outcomes (e.g., unprotected vaginal sex) or biological outcomes (e.g., sexually transmitted infection). Instead, the programs consistently had no effect on participants' incidence of unprotected vaginal sex, frequency of vaginal sex, number of sex partners, sexual initiation, or condom use.

One trial favored an abstinence-only program over usual care for incidence of vaginal sex (n=839), but this was limited to two-month follow-up and was offset by measurement error and six other studies with non-significant effects (n=2615).

One evaluation found several significant adverse (harmful) program effects: abstinence-only program participants were more likely than usual-care controls to report sexually transmitted infections (n=2711), pregnancy (n=1548), and increased frequency of vaginal sex (n=338). These effects were offset by high attrition and other studies showing non-significant effects.

We concluded that abstinence-only programs do not appear to reduce or exacerbate HIV risk among participants in high-income countries, although this evidence might not apply beyond US youth. Trial limitations included underreporting of relevant outcomes, reliance on program participants to report their behaviors accurately, and methodological weaknesses in the trials.



  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要







我們搜尋了30個電子資料庫(例如CENTRAL, PubMed, EMBASE, AIDSLINE, PsycINFO)截至2007年2月為止經互相參照 、手動查詢和專家意見所得到額外的引文則到2007年4月為止




針對納入條件和方法學的品質,三個回顧者獨立地評估了20,070 個紀錄和326篇全文的文獻。由於異質性和資料不可獲得,我們呈現了個別的研究結果而非做一個後設分析(metaanalysis)。


研究牽涉了15,940位美國青年參與者的人種是相異的。7個計畫是以學校為基礎,2個計畫是以社區為基礎,而一個是來自家庭住家。追蹤的中位數出現在基準線後17個月。結果顯示根據自我報導的生物學和行為的結果,沒有一個純粹禁慾計畫的指標可以降低感染人類免疫缺乏病毒的風險。跟許多不同的對照組相比,這些評估的計畫一致的並沒有影響到未受保護的陰道性交發生率、陰道性交的頻率、性伴侶數、初次性行為時間或保險套使用。 有一個研究發現對於最近陰道性交發生率有保護的效果且具統計學意義(n = 839),但受限於追蹤時間較短,且此正面意義被測量上的錯誤和其他6個研究顯示沒有顯著差別(n = 2615)所抵消。另一個研究發現對於性傳染病的發生率(n = 2711), 懷孕發生率(n = 1548)和陰道性交的頻率(n = 338)有顯著地有害的影響但這些影響也因其他研究結果顯示並無意義而抵消。在方法學而言,優點包括族群標本夠大,自我報告的改善及基礎值控制的分析。弱點包括相關結果的未充分使用,關鍵資料的未充分報導,自我報導的偏差和忽略損耗和群聚的隨機分析。





此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。


純粹禁慾計畫為了預防高所得國家(由世界銀行所定義)感染人類免疫缺乏病毒的風險。在美國和美國總統支持下進行愛滋病緩解緊急計畫的國家,純粹禁慾計畫被廣泛且資金充足的推廣。在禁慾是預防感染人類免疫缺乏病毒最好且唯一的方法前提下,純粹禁慾介入計畫目的要預防、杜絕或減少性行為。純粹禁慾計畫不同於禁慾加強計畫:禁慾加強計畫推動了安全性行為策略(例如保險套使用)以及禁慾,但純粹禁慾計畫反而時常強調保險套使用的限制。有一個最近期的回顧認為純粹禁慾計畫並不會影響低收入國家感染人類免疫缺乏病毒的風險 而我們的回顧則檢視了高所得國家研究的証據力。這個回顧包括了13個隨機對照試驗比較了純粹禁慾計畫和各種控制組的差異(例如:一般照護,沒有介入)。我們為了這個試驗做了廣泛的國際搜尋,全部的研究都登記了美國青年(總基本登記人數是15940個參與者)。計畫是實施在學校,社區中心和家庭全部都是以家庭單位或是年輕人的群組來傳送。因為遺失的資料和計畫設計的差異,我們無法進行一個整合分析。然而,從這些個別試驗的發現是明顯一致的。整體來說,根據行為的結果(例如未保護的陰道性交)或是生物結果(例如性傳播感染)來說,這些試驗沒有指出純粹禁慾計畫可以降低感染人類免疫缺乏病毒的風險。反而,這些計畫一致的顯示在參與者的未保護陰道性交發生率、陰道性交頻率、性伴侶數、初次性行為時間或保套使用都是沒有影響的。有一個研究發現對於最近陰道性交發生率有保護的效果且具統計學意義(n = 839),但受限於追蹤時間較短,且此正面意義被測量上的錯誤和其他6個研究顯示沒有顯著差別(n = 2615)所抵消。一個評估發現幾個有意義且有害的計畫影響:純粹禁慾計畫的參與者比上一般照護控制組更有可能造成性傳播感染(n = 2711), 懷孕(n = 1548)和增加的陰道性交頻率(n = 338)。這些影響被高損害和其他顯示無明顯意義的研究所抵消。我們的結論是證據並不能證實純粹禁慾的處置會有效的降低或加重在高所得國家的參與者得到人類免疫缺乏病毒的風險,雖然這個證據可能無法應用於非美國青年。試驗的限制包括未充分報導的相關結果、計畫中的參與者是否準確的報導他們的行為和這些試驗方法學上的弱點。