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

  • Review
  • Intervention

Authors


Abstract

Background

Abstinence-plus interventions promote sexual abstinence as the best means of preventing acquisition of HIV, but also encourage safer-sex strategies (eg condom use) for sexually active participants.

Objectives

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

Search methods

We searched 30 electronic databases (eg CENTRAL, PubMed, EMBASE, AIDSLINE, PsycINFO) ending February 2007. Cross-referencing, hand-searching, and contacting experts yielded additional citations.

Selection criteria

We included randomized and quasi-randomized controlled trials evaluating abstinence-plus interventions in high-income countries (as defined by the World Bank). Interventions were any efforts that encouraged sexual abstinence as the best means of HIV prevention, but also promoted safer sex. Results were self-reported biological outcomes, behavioral outcomes, and HIV knowledge.

Data collection and analysis

Three reviewers independently appraised 20070 citations and 325 full-text papers for inclusion and methodological quality; 39 evaluations were included. Due to heterogeneity and data unavailability, we presented the results of individual studies instead of a meta-analysis.

Main results

Studies enrolled 37724 North American youth; participants were ethnically diverse. Programs took place in schools (10), community facilities (24), both schools and community facilities (2), healthcare facilities (2), and family homes (1). Median final follow-up occurred 12 months after baseline.

Results showed no evidence that abstinence-plus programs can affect self-reported sexually transmitted infection (STI) incidence, and limited evidence that programs can reduce self-reported pregnancy incidence. Results for behavioral outcomes were promising; 23 of 39 evaluations found a significantly protective intervention effect for at least one behavioral outcome. Consistently favorable program effects were found for HIV knowledge.

No adverse effects were observed. Several evaluations found that one version of an abstinence-plus program was more effective than another, suggesting that more research into intervention mechanisms is warranted.

Methodological strengths included large samples and statistical controls for baseline values. Weaknesses included under-utilization of relevant outcomes, self-report bias, and analyses neglecting attrition and clustered randomization.

Authors' conclusions

Many abstinence-plus programs appear to reduce short-term and long-term HIV risk behavior among youth in high-income countries. Evidence for program effects on biological measures is limited. Evaluations consistently show no adverse program effects for any outcomes, including the incidence and frequency of sexual activity. Trials comparing abstinence-only, abstinence-plus, and safer-sex interventions are needed.

摘要

背景

守貞綜合性教育對於高國民所得國家的愛滋病防治之影響

守貞綜合性教育不僅強調避免性行為是防治愛滋病的最好方法,也同時鼓勵性生活活躍的族群從事安全的性行為(例如使用保險套)。

目標

探討守貞綜合性教育對於高國民所得國家的愛滋病防治之成效。

搜尋策略

我們搜尋30個電子資料庫(例如:CENTRAL, PubMed, EMBASE, AIDSLINE, PsycINFO)中,截至2007年2月相關文章。我們也相互參照參考文獻,人工搜尋,並聯絡專家來取得更多的參考文獻。

選擇標準

我們收錄了探討綜合守貞性教育對高所得國家(根據世界銀行定義)影響的隨機對照以及半隨機對照試驗。而綜合守貞性教育不僅包括了強調性行為是防治愛滋病的最佳方法,同時也鼓勵安全的性行為。結果指標自行回報的生物性結果,行為性結果,以及對人類免疫缺乏病毒的知識。

資料收集與分析

3位作者獨立評讀了20070篇的引用文獻以及325篇的全文論文,並根據收入的條件及方法學品質篩選出了39篇論文。由於無法取得詳細的數據以及論文間的異質性,本文將呈現個別研究的結論而不使用統合分析的方式。

主要結論

收入的研究中共包含了37,724名北美青年;參與者包括了不同人種。守貞綜合性教育的實施地點包括了學校(10),社區性機構 (24),學校及社區機構(2),健康照護機構(2),以及家庭(1)。平均的追蹤時間為12個月。結果顯示沒有證據證實守貞綜合性教育能改善自行通報的性傳染疾病發生率。有限的證據顯示守貞綜合性教育能減少自行通報的懷孕率。然而,守貞綜合性教育確實能改善行為結果;在39篇研究中,有23篇顯示教育能顯著的改善至少一項行為結果之保護性介入的成效。而守貞綜合性教育也增進了受測者對人類免疫缺乏病毒的認知。其中,並沒有發現任何不良的結果。數個試驗發現不同版本的守貞綜合性教育有相異的效果。這顯示了守貞綜合性教育的方法值得做更深入的研究。 研究方法上的優點包括樣本數多且。有考量基準的差異統計分析缺點包括:未完全應用相關結果,自行通報的誤差,分析忽略了樣本退出以及採用群族隨機抽樣。

作者結論

多數的守貞綜合性教育都能減少高所得國家之中,青少年短期及長期的感染人類後天免疫疾不全病毒風險性行為。雖然,改善人類免疫不全病毒罹病率的生物學上的證據有限,然而結論也顯示了這並沒有負面的結果,包括性行為的發生率以及頻率。目前仍然需要針對單純的守貞教育,守貞綜合性教育,以及安全性行為教育之間做進一步的對照試驗。

翻譯人

本摘要由臺北榮民總醫院許劭榮翻譯。

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

總結

守貞綜合性教育對於高國民所得國家(根據世界銀行定義)的愛滋病防治之影響。守貞綜合性教育是一種針對年輕族群的廣泛教育方法。在守貞是防治人類免疫缺乏病毒的最好方法的前提下,守貞綜合性教育之目的在預防,阻止或減少性行為。然而,守貞綜合性教育同時也對具性行為活躍的族群推廣保險套的使用以及其他較安全的性行為替代方法。不同於守貞綜合性教育,單純守貞教育只強調守貞是防治感染的唯一的方法,這一篇文獻回顧探討了39篇針對守貞綜合性教育和不同的控制組(如:平時照顧,不介入)的比較,其中包含了隨機控制及半隨機控制試驗。雖然我們試圖做廣泛而國際性的探討,然而所有納入的研究都是針對美國,加拿大以及巴哈馬的青年(共比較了37,724名受試者)。這些試驗在學校,社區機構,以及健康照護機構中進行。由於各個研究之間的差異以及無法獲得詳細的資料,這篇研究並未進行統合分析。我們使用了不同的控制組,在39篇研究中,有24篇顯示在短期中期至長期的追蹤時間,對於至少一項生物學或行為結果有顯著的保護效果。在8篇試驗中顯示,守貞綜合性教育不能改善自行通報的性病發生率。有限的證據顯示守貞綜合性教育對自行通報的懷孕率。有保護效果而各研究結論顯示,而反應在行為上的結果並不一致但幾乎。所有的結論都顯示守貞綜合性教育能增介入組對人類免疫缺乏病毒的瞭解。而結論顯示守貞綜合性教育並沒有任何的害處,包括性行為的發生率和頻率。 這一篇回顧的限制包括:相關結果的低報,依賴參加研究的人正確性地自行通報其結果,以及納入試驗本身不夠完善的研究方法。

Plain language summary

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

Abstinence-plus programs are widespread interventions that primarily target young people. On the premise that sexual abstinence is the best way to prevent HIV, abstinence-plus interventions aim to prevent, stop, or decrease sexual activity; however, programs also promote condom use and other safer-sexstrategies as alternatives for sexually active participants. Abstinence-plus programs differ from abstinence-only interventions, which promote abstinence as the exclusive means of HIV prevention without encouraging safer sex.

This review included 39 randomized and quasi-randomized controlled trials comparing abstinence-plus programs to various control groups (eg "usual care," no intervention). Although we conducted an extensive international search for trials, all included studies were conducted among youth in the US, Canada, and the Bahamas (total baseline enrolment=37724 participants). The included programs took place in schools, community centers, and healthcare facilities. We did not conduct a meta-analysis because of missing data and variation in program designs.

Using various control groups, 24 of 39 evaluations showed a significantly protective intervention effect on at least one biological or behavioral outcome at short-term, medium-term, or long-term follow-up. Eight trials found no evidence that abstinence-plus programs affect self-reported sexually transmitted infection (STI) incidence and limited evidence that programs have a protective effect on self-reported pregnancy incidence. Results for behavioral outcomes were inconsistent across studies. Findings in almost every trial assessing HIV-related knowledge favored the intervention group over controls. No harms were observed for any outcome, including incidence and frequency of sexual activity.

Limitations for this review include underreporting of relevant outcomes, reliance on program participants to report their behaviors accurately, and methodological weaknesses in the trials.

Ringkasan bahasa mudah

Program abstinens-tambahan untuk pencegahan jangkitan HIV di negara-negara berpendapatan tinggi (seperti ditakrifkan oleh Bank Dunia)

Program abstinens-tambahan adalah intervensi yang diguna secara meluas mensasarkan orang muda. Berdasarkan pandangan bahawa abstinens seks adalah cara terbaik untuk mencegah HIV, intervensi abstinens-tambahan bertujuan mencegah, menghentikan, atau mengurangkan aktiviti seksual; namun program tersebut juga menggalakkan penggunaan kondom dan strategi seks lain sebagai alternatif untuk peserta yang aktif secara seksual. Program abstinens-tambahan adalah bebeza dengan intervensi yang menggunakan abstinens sahaja, yang menggalakkan abstinens sebagai cara eksklusif pencegahan HIV tanpa menggalakkan hubungan seks yang selamat.

Ulasan ini merangkumi 39 kajian rambang terkawal dan kuasi-rambang terkawal yang membandingkan program abstinens-tambahan dengan pelbagai kumpulan kawalan (contohnya "penjagaan biasa", tiada intervensi). Walaupun kami telah menjalankan pencarian antarabangsa yang meluas untuk kajian-kajian, semua kajian yang dimasukkan adalah dijalankan dalam kalangan remaja di Amerika Syarikat, Kanada, dan Bahamas (jumlah enrolmen asas = 37724 peserta). Ini termasuklah program-program yang diadakan di sekolah, pusat komuniti, dan kemudahan penjagaan kesihatan. Kami tidak menjalankan meta-analisis kerana data yang tidak lengkap dan kepelbagaian rekabentuk program-program tersebut.

Dengan menggunakan pelbagai kumpulan kawalan, 24 daripada 39 penilaian menunjukkan kesan intervensi perlindungan yang signifikan ke atas sekurang-kurangnya satu hasil biologi atau hasil tingkah laku dalam jangkamasa pendek, jangkamasa sederhana, atau rawatan susulan jangkamasa panjang. Lapan kajian mendapati tiada bukti bahawa program abstinens-tambahan mempengaruhi insiden laporan kendiri jangkitan transmisi seksual (STI) dan bukti terhad bahawa program tersebut mempunyai kesan perlindungan ke atas laporan kendiri insiden kehamilan. Keputusan hasil tingkahlaku adalah tidak konsisten dalam pelbagai kajian. Penemuan kebanyakan kajian yang menilai pengetahuan berkaitan dengan HIV lebih memihak kepada kumpulan intervensi daripada kumpulan kawalan. Tiada kemudaratan diperhatikan untuk sebarang hasil termasuklah insiden dan kekerapan aktiviti seksual.

Limitasi ulasan ini termasuklah kekurangan laporan hasil yang berkaitan, pergantungan kepada peserta program untuk melaporkan tingkahlaku mereka dengan tepat, dan kelemahan metodologi dalam kajian-kajian tersebut.

Catatan terjemahan

Diterjemahkan oleh Raymond Chieng Siang Ching (Melaka Manipal Medical College).Disunting oleh Noorliza Mastura Ismail (Melaka manipal Medical College) Untuk sebarang pertanyaan mengenai terjemahan ini sila hubungi raymondchieng@gmail.com

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