Clinical Question

Do abstinence-plus programs prevent human immunodeficiency virus (HIV) infection?

Evidence-Based Answer

Abstinence-plus is sex education that includes information on abstinence, condom use, and contraception. Compared with a variety of controls—including usual care, no intervention, or other programs—there is no evidence of increased rates of pregnancy or sexually transmitted infection (STI). Based on limited data, abstinence-plus programs increase knowledge, reduce pregnancy rates, and decrease incidence of unprotected sex and frequency of sex.

Practice Pointers

Abstinence-plus interventions are designed to prevent, stop, or decrease sexual activity while promoting safer sex practices for persons who choose to engage in sex. In contrast, abstinence-only interventions promote abstinence as the only way to prevent HIV infection.

In this Cochrane review of randomized and quasi-randomized controlled trials of abstinence-plus interventions, the authors identified 39 studies with a total of 37,724 participants. All studies were conducted on adolescents or young adults in North America, and 37 studies were conducted in the United States. Most of the studies took place in urban schools or community centers, and the participants were primarily of ethnic minorities. Active parental consent was required by 28 of the studies. Interventions varied considerably, but they all promoted abstinence as the best choice and condom or contraception use for those who have sex. Control interventions also varied considerably. All interventions included information on HIV, STI prevention, sexual risks, and strategies for HIV prevention. Interventions ranged from a single session to programs that were three years in duration. Results were self-reported.

Because of methodologic differences, meta-analysis was not possible. There was no evidence that abstinence-plus programs increased the risk of HIV infection, and there were no adverse effects reported. Abstinence-plus education improved participants' knowledge of HIV across trials. Only two studies (with 1,700 participants, total) included STI screening as an outcome. No statistical differences were found among interventions. Limited evidence suggests that abstinence-plus programs reduce the incidence of pregnancy. Limited data also demonstrate a reduction in the incidence of unprotected intercourse and a reduced frequency of vaginal and anal sex.

In a previous review, the authors evaluated 13 trials of abstinence-only programs with a total of 15,940 U.S. adolescent participants.¹ Compared with various controls, the abstinence-only programs did not reduce self-reported biologic (e.g., STIs) or behavioral (e.g., unprotected vaginal sex) outcomes in participants. One study in the review found increases in short- and long-term incidences of STIs, an increased rate of pregnancy, and an increased frequency of vaginal sex (4,652 participants).¹ However, these findings of harm were limited to that one study.