CARLOS F. CACERES, MD, PHD PROFESSOR OF PUBLIC HEALTH CAYETANO HEREDIA UNIVERSITY DIRECTOR, INSTITUTE OF HEALTH, SEXUALTY AND HUMAN DEVELOPMENT LIMA, PERU Comprehensive Sex Education: Evidence Gaps and Research Needs

Well Established Evidence in the US Important Report: Kirby D (2007). Emerging Answers 2007: Research Findings on Programs to Reduce Teen Pregnancy and Sexually Transmitted Diseases. Washington DC: The National Campaign to Prevent Teen and Unplanned Pregnancy. Key Finding: “The quality and quantity of evaluation research in this field has improved dramatically and there is now more persuasive evidence than ever before that a limited number of programs can delay sexual activity, improve contraceptive use among sexually active teens, and/or prevent teen pregnancy”

Well Established Evidence in the US No evidence base to support continued public investment of in rigid abstinence-only-until-marriage programs No abstinence program of the type eligible for funding (under the federal government’s $176 million abstinence-only-until- marriage program) has been found in a methodologically rigorous study to positively impact teen sexual behavior In contrast, the majority of the comprehensive sex education programs —which receive no comparable federal funding—are effective. The positive outcomes included delaying the initiation of sex, reducing the frequency of sex, reducing the number of sexual partners and increasing condom or contraceptive use. Comprehensive sex education programs are well suited for widespread replication and dissemination.

US: Debunking Myths This report also shows that several myths propagated by advocates of abstinence-only education are demonstrably false.  Comprehensive sex education does not promote promiscuity.  Comprehensive sex education does not send a confusing message to adolescents  The benefits of comprehensive sex education programs extend to many areas of decision-making and confidence building among adolescents.

Global Evidence WHO, UNICEF, UNFPA, UNAIDS, LSHTM. (2006) Preventing HIV/AIDS in young people – The first systematic review of what works to prevent HIV among young people in developing countries In schools: Curriculum-based interventions, led by adults, that are based on defined quality criteria, can have an impact on knowledge, skills and behaviors In health services: Interventions can increase young people’s use of services provided that they train service providers, make changes in the facilities to ensure that they are “adolescent-friendly”, and create demand and community support through actions in the community

Global Evidence In the mass media: interventions can have an impact on knowledge and behaviours if they involve a range of media, for example TV and radio supported by other media e.g. print, and are explicit about sensitive issues but in line with cultural sensitivities In communities: increased knowledge and skills can be achieved through interventions that are explicitly directed to young people and work through existing organizations and structures For young people most at-risk: interventions that provide information and services through static and outreach facilities are most effective in reaching young people most at risk of HIV, for example young sex workers, young injecting drug users or young MSM.

Recommendations for Researchers GENERAL Critical need to strengthen research and program M&E capacity in LMIC countries High-quality evaluations and monitoring of the impact of HIV prevention interventions among young people in LMIC countries for “Ready” and “Steady” interventions Operations research to better understand how interventions operate Clarity about the specific vulnerabilities of young people, including young IDU, young SW and young MSM, to guide program managers Standardization of outcome indicators to facilitate comparison of results across studies Costing and cost-effectiveness studies built into evaluation studies Research to better understand the relationship between reported effects on behaviors and biomedical impacts

Recommendations for Researchers SCHOOLS Whenever possible, use randomized designs with sufficiently large samples Measure the impact on STIs &HIV as well as knowledge and self-reported attitudes, self-efficacy and sexual risk behaviors HEALTH SERVICES Evaluation and operations research to be core elements of any interventions to increase young people’s use of health services MASS MEDIA Evaluations of mass media programs focused on those that are comprehensive, have the potential for achieving population effects and use strong quasi-experimental designs to build a case for inferring causality

Recommendations for Researchers COMMUNITIES Evaluation and operations research to be core elements of programs targeting youths & community at large Pay particular attention to identifying conditions for effectiveness among various populations (e.g. young men and young women) and locations (e.g. rural/urban areas) YOUTH MOST AT RISK Research needed to identify special needs of these youths in contrast to those of adults in order to improve indicators to be used for M&E

Other Research Gaps Context-generalizability  Differences across and within countries Especially vulnerable populations  Schools and sexual/gender diversity contexts  Responsiveness to youth’s specific needs  Gender and masculinity  Homophobic bullying – determinants and prevention Religion, religiousity and sex education Positive aspects of sexual health  Conceptualization, indicators Structural Interventions: Settings, strategies, timeframe  Actors, coalitions and policy environment for legal change