No retraction, correction or concern found when last checked on Oct 21, 2026.

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

Virginia A. Fonner, Kevin S. Armstrong, Caitlin E. Kennedy and 2 more

PLoS ONE · 2014 · Meta-analysis

doi:10.1371/journal.pone.0089692

Abstract

Objectives. School-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.

Methods. We 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.

Results. Of 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).

Conclusions. The 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.

References 103

1.
UNAIDS (2012) UNAIDS Report on the Global AIDS Epidemic. Geneva, Switzerland.
Not in our library
2.
Mmari K, Blum RW (2009 ) Risk and protective factors that affect adolescent reproductive health in developing countries: A structured literature review. Global Public Health 4: 350–366.
Not in our library10.1080/17441690701664418
3.
Gallant M, Maticka-Tyndale E (2004 ) School-based HIV prevention programmes for African youth. Soc Sci Med 58: 1337–1351.
Not in our library10.1016/s0277-9536(03)00331-9
4.
Santelli JS, Speizer IS, Edelstein ZR (2013 ) Abstinence promotion under PEPFAR: The shifting focus of HIV prevention for youth. Glob Public Health 8: 1–12.
Not in our library10.1080/17441692.2012.759609
5.
Ott MA, Santelli JS (2007 ) Abstinence and abstinence-only education. Curr Opin Obstet Gynecol 19: 446–452.
Not in our library10.1097/gco.0b013e3282efdc0b
6.
Wagman J, Baumgartner JN, Waszak Geary C, Nakyanjo N, Ddaaki WG, et al (2009 ) Experiences of Sexual Coercion Among Adolescent Women: Qualitative Findings From Rakai District, Uganda. Journal of Interpersonal Violence 24: 2073–2095.
Not in our library10.1177/0886260508327707
7.
Kirby D, Coyle K (1997 ) School-based programs to reduce sexual risk-taking behavior. Children and Youth Services Review 19: 415–436.
Not in our library
8.
A systematic review of school-based sexual health interventions to prevent STI/HIV in sub-Saharan Africa · 2008
Not checked
9.
Speizer IS, Magnani RJ, Colvin CE (2003 ) The effectiveness of adolescent reproductive health interventions in developing countries: a review of the evidence. J Adolesc Health 33: 324–348.
Not in our library10.1016/s1054-139x(02)00535-9
10.
Chin HB, Sipe TA, Elder R, Mercer SL, Chattopadhyay SK, et al (2012 ) The Effectiveness of Group-Based Comprehensive Risk-Reduction and Abstinence Education Interventions to Prevent or Reduce the Risk of Adolescent Pregnancy, Human Immunodeficiency Virus, and Sexually Transmitted Infections: Two Systematic Reviews for the Guide to Community Preventive Services. American Journal of Preventive Medicine 42: 272–294.
Not in our library10.1016/j.amepre.2011.11.006
11.
Denison JA, O'Reilly KR, Schmid GP, Kennedy CE, Sweat MD (2008 ) HIV voluntary counseling and testing and behavioral risk reduction in developing countries: a meta-analysis, 1990–2005. AIDS Behav 12: 363–373.
Not in our library10.1007/s10461-007-9349-x
12.
Fonner VA, Denison J, Kennedy CE, O'Reilly K, Sweat M (2012 ) Voluntary counseling and testing (VCT) for changing HIV-related risk behavior in developing countries. Cochrane Database Syst Rev 9: CD001224.
Not in our library10.1002/14651858.cd001224.pub4
13.
Kennedy CE, Fonner VA, Sweat MD, Okero FA, Baggaley R, et al (2012 ) Provider-Initiated HIV Testing and Counseling in Low- and Middle-Income Countries: A Systematic Review. AIDS Behav
Not in our library10.1007/s10461-012-0241-y
14.
Sweat MD, Denison J, Kennedy C, Tedrow V, O'Reilly K (2012 ) Effects of condom social marketing on condom use in developing countries: a systematic review and meta-analysis, 1990–2010. Bull World Health Organ 90: 613–622A.
Not in our library10.2471/blt.11.094268
15.
Kennedy CE, Medley AM, Sweat MD, O'Reilly KR (2010 ) Behavioural interventions for HIV positive prevention in developing countries: a systematic review and meta-analysis. Bull World Health Organ 88: 615–623.
Not in our library10.2471/blt.09.068213
16.
Medley A, Kennedy C, O'Reilly K, Sweat M (2009 ) Effectiveness of peer education interventions for HIV prevention in developing countries: a systematic review and meta-analysis. AIDS Educ Prev 21: 181–206.
Not in our library10.1521/aeap.2009.21.3.181
17.
Sweat M, O'Reilly K, Kennedy C, Medley A (2007 ) Psychosocial support for HIV-infected populations in developing countries: a key yet understudied component of positive prevention. AIDS 21: 1070–1071.
Not in our library10.1097/qad.0b013e3280f774da
18.
Bertrand JT, O'Reilly K, Denison J, Anhang R, Sweat M (2006 ) Systematic review of the effectiveness of mass communication programs to change HIV/AIDS-related behaviors in developing countries. Health Educ Res 21: 567–597.
Not in our library10.1093/her/cyl036
19.
Kennedy C, O'Reilly K, Medley A, Sweat M (2007 ) The impact of HIV treatment on risk behaviour in developing countries: a systematic review. AIDS Care 19: 707–720.
Not in our library10.1080/09540120701203261
20.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement · 2009
No notice
21.
WorldBank In: Regions Ca, editor.
Not in our library
22.
(1994) The Handbook of research synthesis. In: Cooper HM, Hedges LV, editors. New York:: Russell Sage Foundation.
Not in our library
23.
Hasselblad V, Hedges LV (1995 ) Meta-analysis of screening and diagnostic tests. Psychological Bulletin 117: 167–178.
Not in our library10.1037/0033-2909.117.1.167
24.
Borenstein M, Hedges LV, Higgins JPT, Rothstein HR (2009) Introduction to Meta-Analysis. John Wiley & Sons, Ltd.
Not in our library
25.
Borenstein M, Hedges L, Higgins J, Rothstein;(2005) Comprehensive Meta Analysis (CMA). Version 2.2, Biostat, Englewood NJ
Not in our library
26.
Hedges LV, Vevea JL (1998 ) Fixed-and random-effects models in meta-analysis. Psychological methods 3: 486.
Not in our library
27.
Higgins JPT, Thompson SG, Deeks JJ, Altman DG (2003 ) Measuring inconsistency in meta-analyses. BMJ 327: 557–560.
Not in our library10.1136/bmj.327.7414.557
28.
Agha S (2002 ) An evaluation of the effectiveness of a peer sexual health intervention among secondary-school students in Zambia. AIDS Educ Prev 14: 269–281.
Not in our library10.1521/aeap.14.5.269.23875
29.
Agha S, Van Rossem R (2004 ) Impact of a school-based peer sexual health intervention on normative beliefs, risk perceptions, and sexual behavior of Zambian adolescents. J Adolesc Health 34: 441–452.
Not in our library10.1016/j.jadohealth.2003.07.016
30.
Doyle AM, Ross DA, Maganja K, Baisley K, Masesa C, et al (2010 ) Long-Term Biological and Behavioural Impact of an Adolescent Sexual Health Intervention in Tanzania: Follow-up Survey of the Community-Based MEMA kwa Vijana Trial. PLoS Med 7: e1000287.
Not in our library10.1371/journal.pmed.1000287
31.
Fitzgerald AM, Stanton BF, Terreri N, Shipena H, Li X, et al (1999 ) Use of Western-based HIV risk-reduction interventions targeting adolescents in an African setting. J Adolesc Health 25: 52–61.
Not in our library10.1016/s1054-139x(98)00120-7
32.
Huang H, Ye X, Cai Y, Shen L, Xu G, et al (2008 ) Study on peer-led school-based HIV/AIDS prevention among youths in a medium-sized city in China. Int J STD AIDS 19: 342–346.
Not in our library10.1258/ijsa.2007.007208
33.
Klepp KI, Ndeki SS, Leshabari MT, Hannan PJ, Lyimo BA (1997 ) AIDS education in Tanzania: promoting risk reduction among primary school children. Am J Public Health 87: 1931–1936.
Not in our library10.2105/ajph.87.12.1931
34.
Klepp KI, Ndeki SS, Seha AM, Hannan P, Lyimo BA, et al (1994 ) AIDS education for primary school children in Tanzania: an evaluation study. AIDS 8: 1157–1162.
Not in our library10.1097/00002030-199408000-00019
35.
Lou CH, Zhao Q, Gao ES (2005 ) Effects of high middle school students' learning sex and reproductive health knowledge by Internet. Fudan University Journal of Medical Sciences 32: 289–294.
Not in our library
36.
Lou CH, Zhao Q, Gao ES, Shah IH (2006 ) Can the Internet be used effectively to provide sex education to young people in China? J Adolesc Health 39: 720–728.
Not in our library10.1016/j.jadohealth.2006.04.003
37.
Ross DA, Changalucha J, Obasi AI, Todd J, Plummer ML, et al (2007 ) Biological and behavioural impact of an adolescent sexual health intervention in Tanzania: a community-randomized trial. AIDS 21: 1943–1955.
Not in our library10.1097/qad.0b013e3282ed3cf5
38.
Stanton BF, Li X, Kahihuata J, Fitzgerald AM, Neumbo S, et al (1998 ) Increased protected sex and abstinence among Namibian youth following a HIV risk-reduction intervention: a randomized, longitudinal study. AIDS 12: 2473–2480.
Not in our library10.1097/00002030-199818000-00017
39.
Ye XX, Huang H, Li SH, Xu G, Cai Y, et al (2009 ) HIV/AIDS education effects on behaviour among senior high school students in a medium-sized city in China. Int J STD AIDS 20: 549–552.
Not in our library10.1258/ijsa.2008.008471
40.
Enah C, Sommers M, Moneyham L, Ann Long C, Childs G (2010 ) Piloting an HIV Prevention Intervention for Cameroonian Girls. J Assoc Nurses AIDS Care
Not in our library10.1016/j.jana.2010.02.011

All 103 references

Cited by papers we hold 5

Reads

Read by people on this page

None yet.

Checked or read by AI through naulon

None yet.

A person counts once a day per paper. We keep no cookie and no address: a reader is a hash that changes every day. Any month under five reads shows no number.

Are you an author?

Is this your paper?

Claim it to add your note and be paid when agents cite it. Free.