Preventing Sexually Transmitted Infections Among Adolescents: Title and subTitle BreakA Clash of Ideology and Science

The risk of acquiring a sexually transmitted infection (STI), including the human immunodeficiency virus (HIV), is one of the most significant threats to the health of adolescents.^{1 - 2} In response to heightened concern about high rates of STIs and the threat of HIV among adolescents, the development and implementation of programs designed to prevent STI/HIV-associated sexual risk behaviors is a public health priority. While there is increasing consensus regarding the urgency of intervening to prevent STI/HIV-associated sexual risk behaviors, there is considerable controversy as to the most effective intervention approach to use. Safer-sex approaches address abstinence but emphasize information and training in safer-sex skills and behaviors. Abstinence interventions exclusively emphasize values, attitudes, and skills for postponing sexual intercourse.

Recently, this public health policy controversy has been amplified with the passage of the Welfare Reform Act (Pub L No. 104-193, §510). As part of this law, Congress allocated $50 million annually for 5 years (1998-2002) to states for the provision of abstinence-only programs. To qualify for funding, states had to match every 4 federal dollars with 3 state (or other public or private sector) dollars. Thus, an annual total of approximately $87 million will be allocated for abstinence-only education. This legislation specifically requires funded programs to teach—among other concepts—the social, psychological, and health gains to be realized by abstaining from sex; that abstaining from sexual activity outside marriage is the expected standard for all school-age adolescents; that a mutually faithful monogamous relationship in the context of marriage is the expected standard of human sexual activity; and that abstaining from sexual activity is the only certain way to avoid pregnancy, STIs, and other associated health problems.

While there is much rhetoric, there are surprisingly scant data demonstrating the efficacy of abstinence interventions vs safer-sex interventions; until now, that is. The article by Jemmott and colleagues³ in this issue of THE JOURNAL represents the first randomized controlled trial of an abstinence intervention compared with a safer-sex intervention and an attention-control condition. This methodologically rigorous study provides much needed data for evaluating the relative efficacy of these 2 intervention approaches.

The findings of Jemmott and colleagues³ demonstrate that culturally sensitive, cognitive-behavioral interventions can reduce sexual risk behavior among African American adolescents. The abstinence intervention was effective over a short follow-up period. At 3-month follow-up, adolescents randomized to the abstinence intervention were less likely to report being sexually active compared with adolescents in the control group. These effects were primarily observed among youth who were not sexually experienced at baseline. Among those sexually experienced at baseline, no treatment advantage was observed for the abstinence intervention compared with either the control group (P=.12) or the safer-sex intervention (P=.52). Furthermore, the effects of the abstinence intervention diminished with longer-term follow-up. At 6- and 12-month follow-ups, there was no difference in the proportion of adolescents in the abstinence intervention relative to the control or safer-sex intervention who reported having sexual intercourse.

Conversely, the effects of the safer-sex intervention on condom use were sustained at 6 and 12 months after intervention. At the 3-month follow-up, the safer-sex intervention was primarily more effective in reducing unprotected sexual intercourse among adolescents who were sexually active prior to participating in the project. At the 6- and 12-month follow-ups, the safer-sex intervention still had significant effects on reducing the frequency of unprotected sexual intercourse among adolescents who reported being sexually experienced at preintervention.

A secondary finding addressed a common argument against sexual risk-reduction programs, ie, that such programs implicitly encourage adolescents to engage in sexual activity. In the current study, adolescents in the safer-sex intervention were not more likely to report having sexual intercourse at follow-up than were adolescents in the control group. Among adolescents who reported sexual experience prior to the study, those in the safer-sex intervention reported less frequent sexual intercourse, thus providing evidence contrary to the belief that sex education increases sexual activity.

The findings of Jemmott and colleagues,³ considered in the broader context of the political and philosophical controversy surrounding the Welfare Reform Act, indicate a need to reconsider the role of abstinence programs as an STI-prevention approach. Empirical data substantiating the efficacy of abstinence programs are sorely lacking. Initial studies suggested that abstinence programs could delay adolescents' sexual de but.^{4 - 5} However, findings from Jemmott and colleagues³ fail to identify a long-term advantage for the abstinence intervention relative to the control or safer-sex intervention. Corroborating the results from Jemmott et al are findings from a recent well-designed study⁶ of more than 7000 adolescents that demonstrated no treatment advantage for the abstinence program. Indeed, adolescents receiving the abstinence curriculum, relative to those in the control group, were as likely to become sexually active at the end of a 17-month follow-up and report similar pregnancy and STI rates.⁶ These findings, in conjunction with a comprehensive review of sexual risk-reduction interventions,⁷ suggest that data are inconclusive to assert that abstinence programs are efficacious.

The findings of Jemmott and colleagues replicate and extend prior research^{1 ,8} on STI/HIV sexual risk-reduction interventions. This body of literature has shown that theory-driven, sexual risk-reduction interventions that address abstinence but emphasize social skills, such as sexual communication and condom use, and attempt to modify adolescents' perceptions of peer norms supporting safer sex, are efficacious at reducing STI/HIV-associated behaviors. Overall, the findings from diverse settings (eg, school, community, and clinics) and adolescent populations indicate that enhancing the adoption of STI/HIV-preventive behaviors, while a formidable challenge, is attainable.^{1 ,8}

Given the weight of scientific evidence demonstrating the efficacy of safer-sex interventions and the absence of clear and compelling data demonstrating a significant and consistent treatment advantage for abstinence programs, it is difficult to understand the logic behind the decision to earmark funds specifically for abstinence programs. Unfortunately, much of the public health policy debate appears to have been ideologically motivated rather than empirically driven. However, no matter how widespread, politically viable, or popular a program may be, efficacy in preventing and modifying behaviors associated with STI/HIV must remain the primary criterion by which programs are judged. Any public health policy that constrains the range of STI/HIV-intervention options severely reduces the programmatic flexibility needed to design and implement effective programs.

Clearly, the public health and clinical significance of delaying sexual onset for adolescents and for society in general cannot be overstated. Further studies with larger samples and diverse adolescent populations are needed to confirm the results identified by Jemmott and colleagues. Additionally, there is a need to develop a coordinated research agenda to stimulate basic social and behavioral science research designed to identify the social and behavioral determinants associated with postponing sexual intercourse. Subsequently, empirically derived social and behavioral interventions could be designed, implemented, and rigorously evaluated.

Prevention scientists have acknowledged the importance of tailoring behavioral interventions to be developmentally, culturally, and gender appropriate. Likewise, STI/HIV interventions may be more effective when they are behaviorally appropriate, ie, tailored to adolescents' sexual experiences. For instance, efficacious abstinence programs may have their greatest impact on youth who have not initiated sexual activity. For youth who are sexually active, however, a safer-sex program would be more relevant.

To promote the health of adolescents, public health policy should be empirically driven, not ideologically motivated. Ideologically motivated policy decisions may inadvertently cause a grave disservice to our youth, many of whom are ill-equipped with the knowledge and skills necessary to reduce high-risk sexual behaviors. In the end, we risk jeopardizing the health and well-being of a generation of youth.