The US government has invested $1.4bn in HIV prevention programmes that promote sexual abstinence and marital fidelity, but there is no evidence that these programmes have been effective at changing sexual behaviour and reducing HIV risk, according to a new Stanford University School of Medicine study.
Since 2004, the US President’s Emergency Fund for AIDS Relief, known as PEPFAR, has supported local initiatives that encourage men and women to limit their number of sexual partners and delay their first sexual experience and, in the process, help to reduce the number of teen pregnancies. However, in a study of nearly 500,000 individuals in 22 countries, the researchers could not find any evidence that these initiatives had an impact on changing individual behaviour.
Although PEPFAR has been gradually reducing its support for abstinence and fidelity programmes, the researchers suggest that the remaining $50m or so in annual funding for such programmes could have greater health benefits if spent on effective HIV prevention methods.
“Overall we were not able to detect any population-level benefit from this programme,” said Nathan Lo, a Stanford MD/PhD student and lead author of the study. “We did not detect any effect of PEPFAR funding on the number of sexual partners or upon the age of sexual intercourse. And we did not detect any effect on the proportion of teen pregnancy. “We believe funding should be considered for programs that have a stronger evidence basis,” he added.
Senior author Dr Eran Bendavid said the ineffective use of these funds has a human cost because it diverts money away from other valuable, risk-reduction efforts, such as male circumcision and methods to prevent transmission from mothers to 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, an assistant professor of medicine at Stanford.
PEPFAR was launched in 2004 by President George W Bush with a five-year, $15m investment in global Aids treatment and prevention in 15 countries. The programme has had some demonstrated success: A 2012 study by Bendavid showed that it had reduced mortality rates and saved 740,000 lives in nine of the targeted countries between 2004 and 2008.
However, the programme’s initial requirement that one-third of the prevention funds be dedicated to abstinence and “be faithful” programmes has been highly controversial. Critics questioned whether this approach could work and argued that focusing only on these methods would deprive people of information on other potentially lifesaving options, such as condom use, male circumcision and ways to prevent mother-to-child transmission, and divert resources from these and other proven prevention measures.
In 2008, when President Barack Obama came into office, the one-third requirement was eliminated, but US funds continued to flow to abstinence and “be faithful” programmes, albeit at lower levels. In 2008, $260m was committed to these programmes, but by 2013 by that figure had fallen to $45m.
Although PEPFAR continues to fund abstinence and faithfulness programmes as part of its broader behaviour-based prevention efforts, there is no routine evaluation of the success of these programmes.
“We hope our work will emphasise the difficulty in changing sexual behaviour and the need to measure the impact of these programmes if they are going to continue to be funded,” Lo said. While many in the medical community were critical of the abstinence-fidelity component, no one had ever analysed its real-world impact, Lo said.
To measure the programme’s effectiveness, Lo and his colleagues used data from the Demographic and Health Surveys, a detailed database with individual and household statistics related to population, health, HIV and nutrition. The scientists reviewed the records of nearly 500,000 men and women in 14 of the PEPFAR-targeted countries in sub-Saharan Africa that received funds for abstinence-fidelity programs and eight non-PEPFAR nations in the region. They compared changes in risk behaviours between individuals who were living in countries with US-funded programmes and those who were not.
The scientists included data from 1998 through 2013 so they could measure changes before and after the programme began. They also controlled for country differences, including gross domestic product, HIV prevalence and contraceptive prevalence, and for individuals’ ages, education, whether they lived in an urban or rural environment, and wealth. All of the individuals in the study were younger than 30.
In one measure, the scientists looked at the number of sexual partners reported by individuals in the previous year. Among the 345,000 women studied, they found essentially no difference in the number of sexual partners among those living in PEPFAR-supported countries compared with those living in areas not reached by PEPFAR programmes. The same was true for the more than 132,000 men in the study.
The researchers also looked at the age of first sexual intercourse among 178,000 women and more than 71,000 men. Among women, they found a slightly later age of intercourse among women living in PEPFAR countries versus those in non-PEPFAR countries, but the difference was slight – fewer than four months – and not statistically significant. Again, no difference was found among the men.
Finally, they examined teenage pregnancy rates among a total of 27,000 women in both PEPFAR-funded and non-funded countries and found no difference in rates between the two.
Bendavid noted that, in any setting, it is difficult to change sexual behaviour. For instance, a 2012 federal Centres for Disease Control analysis of US-based abstinence programmes found they had little impact in altering high-risk sexual practices in this country.
“Changing sexual behaviour is not an easy thing,” Bendavid said. “These are very personal decisions. 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. Behavioural change is much more complicated than that.”
The one factor that the researchers found to be clearly related to sexual behaviour, particularly in women, was education level. Women with at least a primary school education had much lower rates of high-risk sexual behaviour than those with no formal education, they found. “One would expect that women who are educated have more agency and the means to know what behaviours are high-risk,” Bendavid said. “We found a pretty strong association.”
The researchers concluded that the “study contributes to the growing body of evidence that abstinence and faithfulness campaigns may not reduce high-risk sexual behaviours and supports the importance of investing in alternative evidence-based programmes for HIV prevention in the developing world.”
The authors noted that PEPFAR representatives have been open to discussing these findings and the implications for funding decisions regarding HIV prevention programmes.
The President’s Emergency Plan for AIDS Relief (PEPFAR) has been 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. We examined whether PEPFAR funding for abstinence and faithfulness programs, which aimed to reduce the risk of HIV transmission, was associated with a relative change in five outcomes indicative of high-risk sexual behavior: number of sexual partners in the past twelve months for men and for women, age at first sexual intercourse for men and for women, and teenage pregnancies. Using nationally representative surveys from twenty-two sub-Saharan African countries, we compared trends between people living in countries that received PEPFAR abstinence and faithfulness funding and those living in countries that did not in the period 1998–2013. We found no evidence to suggest that PEPFAR funding was associated with population-level reductions in any of the five outcomes. These results suggest that alternative funding priorities for HIV prevention may yield greater health benefits.