“Abstinence promotion” policies the United States has funded for more than a decade as part of an effort to slow the spread of HIV in sub-Saharan Africa are largely ineffective, a new evaluation of the program concludes.
The U.S. has spent more than $1.4 billion since 2004 telling young people in Africa to abstain from sex before marriage and then commit to a single partner. That funding didn’t influence the number of sex partners people had, the age at which they started having sex, or teen pregnancy rates, according to a study published on Monday in the journal Health Affairs by researchers at the Stanford School of Medicine.
The abstinence policies are a controversial part of former President George W. Bush’s ambitious program to fight HIV, the virus that causes AIDS, around the globe, and they have continued under President Obama. The broader effort, known as the President’s Emergency Plan for AIDS Relief, or Pepfar, is widely considered a global health success. It has delivered life-saving HIV medicines to millions of people, largely in poor countries in sub-Saharan Africa, at a cost of more than $50 billion since 2004. The program "reset the world's expectations for what can be accomplished with ambitious goals, ample funding, and humanitarian commitment to a public health crisis,” according to a 2013 evaluation by the Institute of Medicine.
From the start, though, Pepfar was subject to certain ideological restrictions. The money couldn’t go to needle exchanges or to organizations that didn’t have policies explicitly opposing prostitution. Of Pepfar's prevention funding, the law required at least a third to go to programs focused on abstinence and faithfulness. That restriction was loosened in 2008, but the U.S. has continued to devote tens of millions of dollars a year to such programs.
The policy clashed with the reality of the HIV epidemic on the ground in Africa. For example, the 2013 Institute of Medicine report noted the “inherent mismatch between an abstinence/be faithful approach and programs for individuals engaged in sex work,” who are an important target for HIV prevention efforts. The Health Affairs report adds that abstinence promotion may be funded “at the opportunity cost of other, potentially more effective, prevention services,” such as promoting condoms or treatment to prevent HIV-positive mothers from passing the virus on to newborns.
The study has some limits. It didn’t compare individual people who had received abstinence education with those who had not, and researchers may not have been able to control for all the differences between the countries they compared.
A spokeswoman for Pepfar didn’t respond to questions about current funding for abstinence programs or whether Pepfar plans to continue them. In an e-mailed statement, Pepfar said it has “continually evolved its approach,” based on the latest evidence.
Additional evaluations of abstinence policies have found little evidence that they work. An analysis by researchers from the Centers for Disease Control and Prevention in 2012 that looked at 23 studies on abstinence education, mostly in the U.S., found "inconsistent findings" and couldn’t draw any conclusions as to how effective they were.
The Health Affairs study, funded by the Doris Duke Charitable Foundation and the Center on the Demography and Economics of Health and Aging at Stanford, provides further evidence along those lines. Stanford researchers used survey data from more than 477,000 men and women. At the country level, they found no meaningful effect from the promotion of abstinence.
Pepfar has had many successes. It appears that an expensive experiment in promoting abstinence isn’t one of them.