How Effective is Comprehensive Sexuality Education in Preventing HIV?

“In this region, in 2013, Ministers of Health and Education from 20 countries endorsed the Eastern and Southern African (ESA) Commitment to scale up access to quality CSE, as well as Sexual and Reproductive Health (SRH) and HIV prevention for adolescents and young people. Specifically, it sets a target that by 2020, ninety per cent of teachers are trained in CSE and that at least 90 per cent of schools have CSE curricula integrated.”

Based on a literature review, this brief discusses the effectiveness of comprehensive sexuality education (CSE) in preventing HIV, and lists key findings and recommendations for the way forward. As explained in the brief, “CSE is a rights-based and gender-focused approach to sexuality education, whether in school or out of school. It refers to curriculum-based, age-appropriate, culturally relevant and scientifically accurate sexuality education that provides balanced information about relationships, safer sex including condoms, contraception, partner reduction and abstinence.”

The literature for this review was sourced through multiple electronic databases, and included grey literature. Literature deemed eligible for the review included systematic reviews, and intervention evaluations of specific CSE programmes conducted in East or Southern Africa between 2005 and 2015. In total, four systematic reviews were found and a total of seven papers published after the latest systematic review. As noted in the brief,  there are very few rigorous evaluations of out-of-school interventions from East and Southern Africa.

The review offers a summary of the evidence for the effectiveness of CSE programmes on HIV and other sexual and reproductive health (SRH) outcomes such as HIV knowledge increase, condom use increase, multiple partner decrease, and increased efficiency for HIV prevention to mention just a few. The research results are categorised in a table according to these HIV/SRH outcomes and divided up into what outcomes were: effective, promising, conflicting, or ineffective. 

Overall key findings for in-school interventions showed that, “[T]here is strong evidence that in-school CSE leads to improved knowledge, increased condom use, decrease in multiple partners, increase in self-efficacy for HIV protection, favourable attitudes to safer sex and delays in initiation of first sexual intercourse. When CSE has an explicit gender and rights focus, better health outcomes are noted.  Not only HIV knowledge, attitudes and behaviours related to sexual risk are improved but also wider SRH outcomes such as access to SRHR services. While the evidence for the impact of CSE to decrease HIV incidence is limited in East and Southern Africa, there is strong evidence that CSE decreases HIV risk behaviours including Intimate Partner Violence, as well as biological outcomes such as HSV-2 [Herpes simplex virus] which is a co-factor for HIV.  The evidence clearly shows that CSE does not lead to negative outcomes such as high-risk behaviour or earlier sexual debut, while abstinence-only programmes have been shown to be largely ineffective in preventing HIV and related undesirable SRH outcomes." 

Related to out-of-school youth the review looks at evidence from East and Southern Africa and abroad (mainly the United States). Interventions were found to be effective in reducing STI prevalence and intimate partner violence by men. Promising results were shown for the outcomes related to transactional sex in men, an increase in HIV knowledge, and increase in condom use.

The policy brief then looks at some of the barriers to implementation and offers recommended strategies for the way forward. The following are just a selection of some of the barriers and the recommended strategies:

• Resistance to CSE by parents, educators and broader community - Recommendations are:  advocate with education sector; develop and implement programmes for parents that strengthen their skills;  and advocate at national and local levels, and engage communities to promote the benefits and importance of CSE, in partnership with young people.
• Lack of of well-trained CSE teachers; teachers are often judgemental and uncomfortable discussing sensitive sexuality issues with young people-  Recommendation are: institutionalise participatory, interactive approaches to CSE in pre-service and in-service teacher training; and support teachers to clarify their personal and professional values and attitudes within CSE training.
• High levels of gender-based violence, sexual abuse and transactional sexual practices  - Reommendtions are: address structural barriers to SRHR for adolescents and young people; strengthen legal frameworks for addressing gender-based violence; strengthen livelihood options for young women; and increase focus on gender norms for both girls and boys.

The last section of the brief offers a list of research gaps which include: studies with long-term follow-up to capture the impact of CSE, including on HIV incidence and safer sex behaviour; qualitative studies to better understand the experiences of young people with CSE; and evaluations of the effectiveness of out-of-school CSE interventions in the East and Southern African region.

The brief concludes that “CSE is effective in decreasing HIV risk factors in adolescents and young people, and improving SRH in general, including creating demand for SRH services. When programmes are designed with a gender, empowerment and rights focus, along with appropriately trained staff to deliver CSE through participatory learning approaches, beneficial outcomes have been demonstrated on knowledge, attitudes, self-efficacy and SRH outcomes.”