Safer-sex education leads to fewer episodes of unprotected sex

Teaching young women how to prevent sexually transmitted infections (STIs) increases condom use and might reduce their number of sexual partners, but little research exists on whether educational programs reduce rates of STIs such as human papillomavirus, according to an updated research review from England.

Human papillomavirus, or HPV, is the most common sexually transmitted infection. HPV infection affects nearly 20 million Americans — an estimated 50 percent of all sexually active men and women - and is the virus behind both genital warts and cervical cancer, according to the Centers for Disease Control and Prevention.

"When people talk about preventing cervical cancer, they usually refer to screening programs or to HPV vaccination. Whilst these are very important strategies, the potential of primary prevention via sexual risk reduction behaviors is often overlooked," said Jonathan Shepherd, Ph.D., a principal research fellow at the University of Southampton in the United Kingdom.

Lead author Shepherd and colleagues studied 23 randomized controlled trials designed to reduce sexual risk behaviors in women 25 and younger, a group particularly vulnerable to HPV infection. Most of the education programs took place in the United States in health care or family planning clinics.

Though all of the programs differed, many provided factual information about STIs, taught women how to obtain and use condoms and discussed other safer-sex skills, such as reducing the number of sexual partners. Some of the studies examined how participation in the trials influenced STI rates.

The review was published by The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews like this one draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic. The current review updates a review originally published in 2000.

When it came to analyzing how the safer sex programs influenced behavior, researchers discovered mixed results.

"Condom use was the most widely reported behavioral outcome measure and many studies reported significant effects for the intervention, notably on measures such as decreasing the number of episodes of unprotected intercourse or increasing the number of episodes of protected intercourse," Shepherd said.

"Condoms are effective, but are not the end-all for preventing HPV," said Lois Ramondetta, M.D., an associate professor of gynecologic oncology at the University of Texas MD Anderson Cancer Center in Houston. "The [HPV] vaccine is really more effective than condom use," Ramondetta said.

She noted that though the title of the review references cervical cancer interventions, most of the studies do not specifically discuss cervical cancer and HPV.

The reviewers also found that in nine of 12 trials, young women who underwent safer-sex education had fewer episodes of unprotected sex, compared to young women who did not participate in the behavioral education program. In four of 12 trials, young women who had the safer-sex education reported having fewer sexual partners during the study follow-up period, though only one of those trials was considered statistically significant.

Overall, safer-sex education programs appeared to have little influence on how many women engaged in sex. The authors reported that none of the programs affected abstinence rates.

Only 12 of the 23 studies included in the review examined whether safer sex education influenced STI transmission rates. Three studies found that safer sex education reduced risk of chlamydia transmission, but for gonorrhea and trichomoniasis, the behavioral program did not change infection rates.

None of the studies examined how the behavioral program affected human papillomavirus infection rates. "The studies are probably too small in terms of numbers of young women included to be conclusive about whether or not behavioral interventions can prevent infections," Shepherd said.

He also noted that most of the studies only measured short-term effects. Most of the studies only followed the women six to 12 months after the trials. "It may be the case that, given adequate time, young women learn to adopt safer sexual behaviors and make it routine in their lives. Conversely, we don't know whether favorable risk reduction behaviors, once learned, are maintained in years to come," Shepherd said.

"This is the only cancer that we know the cause, that has a pre-invasive phase that's curable, and has a vaccine. There's really no reason for this to be in existence today," Ramondetta said.