Intended for healthcare professionals


Sexual abstinence only programmes to prevent HIV infection in high income countries: systematic review

BMJ 2007; 335 doi: (Published 02 August 2007) Cite this as: BMJ 2007;335:248
  1. Kristen Underhill, research officer,
  2. Paul Montgomery, lecturer,
  3. Don Operario, lecturer
  1. Centre for Evidence-Based Intervention, University of Oxford, Oxford OX1 2ER
  1. Correspondence to: K Underhill kristen.underhill{at}
  • Accepted 4 June 2007


Objective To assess the effects of sexual abstinence only programmes for HIV prevention among participants in high income countries.

Design Systematic review.

Data sources 30 electronic databases without linguistic or geographical restrictions to February 2007, contacts with experts, hand searching, and cross referencing.

Review methods Two reviewers independently applied inclusion criteria and extracted data, resolving disagreements by consensus and referral to a third reviewer. Randomised and quasirandomised controlled trials of abstinence only programmes in any high income country were included. Programmes aimed to prevent HIV only or both pregnancy and HIV. Trials evaluated biological outcomes (incidence of HIV, sexually transmitted infection, pregnancy) or behavioural outcomes (incidence or frequency of unprotected vaginal, anal, or oral sex; incidence or frequency of any vaginal, anal, or oral sex; number of partners; condom use; sexual initiation).

Results The search identified 13 trials enrolling about 15 940 US youths. All outcomes were self reported. Compared with various controls, no programme affected incidence of unprotected vaginal sex, number of partners, condom use, or sexual initiation. One trial observed adverse effects at short term follow-up (sexually transmitted infections, frequency of sex) and long term follow-up (sexually transmitted infections, pregnancy) compared with usual care, but findings were offset by trials with non-significant results. Another trial observed a protective effect on incidence of vaginal sex compared with usual care, but this was limited to short term follow-up and countered by trials with non-significant findings. Heterogeneity prevented meta-analysis.

Conclusion Programmes that exclusively encourage abstinence from sex do not seem to affect the risk of HIV infection in high income countries, as measured by self reported biological and behavioural outcomes.


  • We thank the Centre for Evidence-Based Intervention and the Department of Social Policy and Social Work at the University of Oxford for internal support; the Cochrane HIV/AIDS Group, Nandi Siegfried, Gail Kennedy, Tara Horvath, and George Rutherford for editorial support; Karishma Busgeeth (trial search coordinator, Cochrane HIV/AIDS Group) for the searches of CENTRAL, PubMed, Embase, and AIDSLINE; the experts on HIV prevention who responded to queries for unpublished and ongoing research; the experts who provided trial search and statistical guidance; and the trialists who provided additional information about their primary studies.

  • Contributors: All authors designed the review, wrote the protocol, applied inclusion criteria, and extracted data. KU carried out supplementary searches and entered trial data into RevMan, which were checked by DO and PM. All authors contributed to writing and editing the final report. KU is the guarantor.

  • Funding: None.

  • Competing interests: None declared.

  • Ethical approval: This review dealt entirely with secondary sources. Ethical approval was secured through the Department of Social Policy and Social Work, University of Oxford.

  • Accepted 4 June 2007
View Full Text