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Meta-Analysis
. 2016 Nov 8;11(11):CD006417.
doi: 10.1002/14651858.CD006417.pub3.

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

Amanda J Mason-Jones  1 , David Sinclair, Catherine Mathews, Ashraf Kagee, Alex Hillman, Carl Lombard
Affiliations
Meta-Analysis

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

Amanda J Mason-Jones et al. Cochrane Database Syst Rev. .

Abstract

Background: School-based sexual and reproductive health programmes are widely accepted as an approach to reducing high-risk sexual behaviour among adolescents. Many studies and systematic reviews have concentrated on measuring effects on knowledge or self-reported behaviour rather than biological outcomes, such as pregnancy or prevalence of sexually transmitted infections (STIs).

Objectives: To evaluate the effects of school-based sexual and reproductive health programmes on sexually transmitted infections (such as HIV, herpes simplex virus, and syphilis), and pregnancy among adolescents.

Search methods: We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) for published peer-reviewed journal articles; and ClinicalTrials.gov and the World Health Organization's (WHO) International Clinical Trials Registry Platform for prospective trials; AIDS Educaton and Global Information System (AEGIS) and National Library of Medicine (NLM) gateway for conference presentations; and the Centers for Disease Control and Prevention (CDC), UNAIDS, the WHO and the National Health Service (NHS) centre for Reviews and Dissemination (CRD) websites from 1990 to 7 April 2016. We handsearched the reference lists of all relevant papers.

Selection criteria: We included randomized controlled trials (RCTs), both individually randomized and cluster-randomized, that evaluated school-based programmes aimed at improving the sexual and reproductive health of adolescents.

Data collection and analysis: Two review authors independently assessed trials for inclusion, evaluated risk of bias, and extracted data. When appropriate, we obtained summary measures of treatment effect through a random-effects meta-analysis and we reported them using risk ratios (RR) with 95% confidence intervals (CIs). We assessed the certainty of the evidence using the GRADE approach.

Main results: We included eight cluster-RCTs that enrolled 55,157 participants. Five trials were conducted in sub-Saharan Africa (Malawi, South Africa, Tanzania, Zimbabwe, and Kenya), one in Latin America (Chile), and two in Europe (England and Scotland). Sexual and reproductive health educational programmesSix trials evaluated school-based educational interventions.In these trials, the educational programmes evaluated had no demonstrable effect on the prevalence of HIV (RR 1.03, 95% CI 0.80 to 1.32, three trials; 14,163 participants; low certainty evidence), or other STIs (herpes simplex virus prevalence: RR 1.04, 95% CI 0.94 to 1.15; three trials, 17,445 participants; moderate certainty evidence; syphilis prevalence: RR 0.81, 95% CI 0.47 to 1.39; one trial, 6977 participants; low certainty evidence). There was also no apparent effect on the number of young women who were pregnant at the end of the trial (RR 0.99, 95% CI 0.84 to 1.16; three trials, 8280 participants; moderate certainty evidence). Material or monetary incentive-based programmes to promote school attendanceTwo trials evaluated incentive-based programmes to promote school attendance.In these two trials, the incentives used had no demonstrable effect on HIV prevalence (RR 1.23, 95% CI 0.51 to 2.96; two trials, 3805 participants; low certainty evidence). Compared to controls, the prevalence of herpes simplex virus infection was lower in young women receiving a monthly cash incentive to stay in school (RR 0.30, 95% CI 0.11 to 0.85), but not in young people given free school uniforms (Data not pooled, two trials, 7229 participants; very low certainty evidence). One trial evaluated the effects on syphilis and the prevalence was too low to detect or exclude effects confidently (RR 0.41, 95% CI 0.05 to 3.27; one trial, 1291 participants; very low certainty evidence). However, the number of young women who were pregnant at the end of the trial was lower among those who received incentives (RR 0.76, 95% CI 0.58 to 0.99; two trials, 4200 participants; low certainty evidence). Combined educational and incentive-based programmesThe single trial that evaluated free school uniforms also included a trial arm in which participants received both uniforms and a programme of sexual and reproductive education. In this trial arm herpes simplex virus infection was reduced (RR 0.82, 95% CI 0.68 to 0.99; one trial, 5899 participants; low certainty evidence), predominantly in young women, but no effect was detected for HIV or pregnancy (low certainty evidence).

Authors' conclusions: There is a continued need to provide health services to adolescents that include contraceptive choices and condoms and that involve them in the design of services. Schools may be a good place in which to provide these services. There is little evidence that educational curriculum-based programmes alone are effective in improving sexual and reproductive health outcomes for adolescents. Incentive-based interventions that focus on keeping young people in secondary school may reduce adolescent pregnancy but further trials are needed to confirm this.

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Conflict of interest statement

Two review authors (AMJ and CM) are investigators in an ongoing study evaluating the effects of school‐based HIV and intimate partner violence prevention intervention programme on biologically measured pregnancy outcome for adolescents. DS has no known conflicts of interest. AK has no known conflicts of interest. AH has no known conflicts of interest. CL has no known conflicts of interest.

Figures

1
1
Logic model showing potential causal chain from influencing factors to impact.
2
2
Study flow diagram.
3
3
'Risk of bias' summary: review authors' judgements about each 'Risk of bias' item for each included study.
1.1
1.1. Analysis
Comparison 1 Educational interventions versus no intervention, Outcome 1 HIV prevalence.
1.2
1.2. Analysis
Comparison 1 Educational interventions versus no intervention, Outcome 2 HSV2 prevalence.
1.3
1.3. Analysis
Comparison 1 Educational interventions versus no intervention, Outcome 3 Syphilis prevalence.
1.4
1.4. Analysis
Comparison 1 Educational interventions versus no intervention, Outcome 4 Pregnancy prevalence (short‐term).
1.5
1.5. Analysis
Comparison 1 Educational interventions versus no intervention, Outcome 5 Pregnancy prevalence (long‐term).
1.6
1.6. Analysis
Comparison 1 Educational interventions versus no intervention, Outcome 6 Self‐reported sexual debut.
1.7
1.7. Analysis
Comparison 1 Educational interventions versus no intervention, Outcome 7 Self‐reported use of condom at first sex.
1.8
1.8. Analysis
Comparison 1 Educational interventions versus no intervention, Outcome 8 Self‐reported use of condom at last sex.
2.1
2.1. Analysis
Comparison 2 Incentive‐based interventions versus no intervention, Outcome 1 HIV prevalence.
2.2
2.2. Analysis
Comparison 2 Incentive‐based interventions versus no intervention, Outcome 2 HSV2 prevalence.
2.3
2.3. Analysis
Comparison 2 Incentive‐based interventions versus no intervention, Outcome 3 Syphilis prevalence.
2.4
2.4. Analysis
Comparison 2 Incentive‐based interventions versus no intervention, Outcome 4 Pregnancy prevalence (short‐term).
2.5
2.5. Analysis
Comparison 2 Incentive‐based interventions versus no intervention, Outcome 5 Pregnancy prevalence (long‐term).
2.6
2.6. Analysis
Comparison 2 Incentive‐based interventions versus no intervention, Outcome 6 Self‐reported sexual debut.
2.7
2.7. Analysis
Comparison 2 Incentive‐based interventions versus no intervention, Outcome 7 Self‐reported use of condom at last sex.
3.1
3.1. Analysis
Comparison 3 Combined incentive‐based and educational interventions versus no intervention, Outcome 1 HIV prevalence.
3.2
3.2. Analysis
Comparison 3 Combined incentive‐based and educational interventions versus no intervention, Outcome 2 HSV2 prevalence.
3.3
3.3. Analysis
Comparison 3 Combined incentive‐based and educational interventions versus no intervention, Outcome 3 Pregnancy prevalence (short‐term).
3.4
3.4. Analysis
Comparison 3 Combined incentive‐based and educational interventions versus no intervention, Outcome 4 Pregnancy prevalence (long‐term).
3.5
3.5. Analysis
Comparison 3 Combined incentive‐based and educational interventions versus no intervention, Outcome 5 Self‐reported sexual debut.
3.6
3.6. Analysis
Comparison 3 Combined incentive‐based and educational interventions versus no intervention, Outcome 6 Self‐reported use of condom at last sex.
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NCT01233531 {published data only}
    1. NCT01233531. Effects of cash transfer for the prevention of HIV in young South African women. clinicaltrials.gov/ct2/show/NCT01233531?term=hptn+068&rank=1 (first received 1 November 2010).
NCT02455583 {published data only}
    1. NCT02455583. An assessment of an HIV prevention intervention (Project AIM) on youth sexual intentions, sexual behaviors and HSV‐2 incidence and prevalence in junior secondary schools in Eastern Botswana. clinicaltrials.gov/ct2/show/NCT02455583 (first received 6 January 2015).
NCT02665091 {published data only}
    1. NCT02665091. Peer education program for HIV/AIDS related sexual behaviors of secondary school students [Impact of peer education program on HIV/AIDS related sexual behaviors of secondary school students in rural communities, India: a quasi‐experimental study.]. clinicaltrials.gov/ct2/show/record/NCT02665091 (first received 22 January 2016).

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References to other published versions of this review

Mason‐Jones 2011
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