The United States has spent $1.4 billion over the last decade on promoting abstinence in Africa as a way to slow the spread of HIV. It hasn’t helped, according to a study published this week in Health Affairs, and may be causing more harm than good.
Researchers Nathan C. Lo, Anita Lowe, and Eran Bendavid from the Stanford School of Medicine evaluated the health records of 500,000 men and women in 22 African countries that receive funding for abstinence promotion from a US initiative, the President’s Emergency Plan for AIDS Relief better known as PEPFAR, and those that do not.
The program follows the “ABC approach“—abstinence until marriage, be faithful to one’s spouse, and correct and consistent condom use—also known as “abstinence plus.” The goal is to dissuade youth from becoming sexually active at an early age, limit the number of sexual partners, and reduce teen pregnancy.
The researchers, funded by the Doris Duke Charitable Foundation and Stanford’s Center on the Demography and Economics of Health and Aging, found that PEPFAR funding had no discernible effect on the number of sexual partners people had or how early they became sexually active. Rates of teen pregnancy were also the same in countries receiving PEPFAR funding and those without.
“Changing sexual behavior is not an easy thing,” says Bendavid, an assistant professor of medicine at Stanford and one of the study’s authors. “When individuals make decisions about sex, they are not typically thinking about the billboard they may have seen or the guy who came by the village and said they should wait until marriage.”
Despite questions about the effectiveness of abstinence programs, there have been no analyses of the real world impacts of PEPFAR’s funding of such efforts, according to Lo, the study’s lead author. A 2012 study from the Centers for Disease Control found that US abstinence programs had little impact on sexual practices.
“We hope our work will emphasize the difficulty in changing sexual behavior and the need to measure the impact of these programs if they are going to continue to be funded,” Lo said.
Started by former president George W. Bush, the PEPFAR program overall is seen as a success and credited with getting HIV medicine to millions of people in Africa. A 2012 study by Bendavid concluded that the program had helped lower mortality rates and saved the lives of 740,000 in nine PEPFAR targeted countries between 2004 and 2008.
But controversially the program once required that one third of all AIDS prevention funding go toward abstinence programs. That requirement was dropped under president Barack Obama’s administration, which has continued PEPFAR, but $45 million a year still goes toward abstinence and “be faithful” programs.
The researchers contend that abstinence programs divert funding away from measures that reduce the risk of AIDs such as male circumcision or ways of preventing AIDS transmission between mothers and their children.
“Spending money and having no effect is a pretty costly thing because the money could be used elsewhere to save lives,” said Bendavid.