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Abstinence promotion efforts funded as part of HIV prevention programmes in Sub-Saharan Africa have failed to reduce risky sexual behaviours, a study has found.
Some US-funded programmes, including the US President’s Emergency Plan for AIDS Relief (PEPFAR), promote abstinence from sex and faithfulness to one sexual partner as a way to prevent HIV transmission.
But scientific research “provides mixed evidence on the efficacy” of abstinence and faithfulness promotion, says the study.
PEPFAR was “the largest funder of abstinence and faithfulness programming in Sub-Saharan Africa, with a cumulative investment of over US$1.4 billion in the period 2004-13”, according to the paper, published in the May issue of Health Affairs.
But the authors “were not able to detect any population-level benefit from this programme”, said lead author Nathan Lo, a medical PhD candidate at Stanford University in the United States, in a statement on 2 May.
Using figures from the US-funded Demographic and Health Surveys database, Lo’s team found no significant difference in “high-risk sexual behaviours” between people in 14 African countries that received PEPFAR support for abstinence and faithfulness between 1998 and 2013, and those in eight countries that did not receive such funding.
The team compared the reported numbers of sexual partners in the past year, the ages at first sexual intercourse and the rates of teenage pregnancy in both groups of countries. They found “no evidence” that PEPFAR funding improved any of these outcomes, and suggest that HIV prevention should focus on other funding priorities that may “yield greater health benefits”, such as distributing free condoms and educating people on risk.The study included a representative sample of about 478,000 people under 30 years old in the 14 countries where PEPFAR was active, but the researchers were unable to distinguish between those the abstinence programmes within each country did or did not reach.
“I would not conclude [from this research] that abstinence promotion does not work,” says Justin Parkhurst, a global health policy researcher at the London School of Hygiene & Tropical Medicine in the United Kingdom.
Abstinence education is not a simple variable that works on everybody in the same way, like some vaccines or drugs, Parkhurst explains. "If a goal of a programme is to reduce coital frequency, or delay onset of sex, this needs to be done in ways that take into account the reasons why people are engaging in these practices in the first place," he says. "Simply telling people to abstain is unlikely to achieve results – and telling people what to do is a pretty poor way to try to promote a behaviour in any case."
Sarah Hand, chief executive officer of UK charity AVERT, which provides HIV and AIDS prevention services in Sub-Saharan Africa, echoes Parkhurst’s concerns.
Lo’s paper “reminds us that it’s vital not to look for quick fixes in HIV prevention”, she says. On the contrary, fighting HIV transmission requires long-term interventions that take into account the sexual norms and practices, and the social and religious context of people who are vulnerable to HIV, “not just the mechanics of how one becomes infected”, Hand says.
Parkhurst agrees about the need for cultural perspective. “Telling people to not have sex is incredibly complicated,” he says, adding that HIV prevention workers need to understand a community’s context to tailor their message to its needs.
This article was amended on 25 May to include an additional quote by Justin Parkhurst.