Nearly $1.3bn spent on US-funded programmes to promote abstinence and faithfulness in sub-Saharan Africa had no significant impact on sexual behaviour in 14 countries in sub-Saharan Africa, an analysis of sexual behaviour data has shown, says researcher Nathan Lo of Stanford University School of Medicine.
The President’s Emergency Plan for AIDS Relief (PEPFAR) was launched in 2004 with a Congressional earmark, or requirement, for a fixed proportion of PEPFAR prevention funds to be spend on programmes promoting abstinence from sexual relations, delaying sexual activity and faithfulness to one partner. Programmes supported by this funding stream also promoted partner reduction. Legislation required one-third of all PEPFAR prevention funding to be spent on this area of work. In 2008, the legislative requirement changed: since then, programmes have been required to justify to Congress why they spend less than 50% of prevention funding on these programmes.
Funding for the programmes peaked at $200m a year in 2008, but declined to around $50m in 2013, as money has been directed to other measures with stronger evidence of effectiveness. Programmes aimed to delay sexual debut in order to reduce the period of high risk during adolescence, especially for girls, and to reduce partner numbers. Although there may be epidemiological grounds for thinking that delaying sexual debut and reducing sexual activity might reduce opportunities for acquiring HIV, evidence for effective interventions was lacking when Congress earmarked funding.
The analysis carried out by a team at Stanford School of Medicine was designed to determine whether the implementation of abstinence and faithfulness-based prevention programming had had a significant impact on the sexual behaviours it was designed to address. The researchers looked at trends in sexual behaviour derived from national Demographic and Health Surveys in 14 PEPFAR focus countries before and after the beginning of PEPFAR funding in 2004, and compared these to a counterfactual: trends in eight other African countries – largely in West Africa – where PEPFAR funding was not determining the content of prevention campaigns.
By looking at trends in behaviour prior to the introduction of PEPFAR funding, the analysis was able to detect whether year-on-year changes were out of the ordinary, and whether shifts in behaviour either followed the long-term trend or deviated from it.
In order to measure the impact of abstinence and faithfulness messages, they looked at the number of sexual partners in the previous year for both men and women, age at first sexual intercourse for men and women, and female teenage pregnancy. They found no significant change in PEPFAR countries relative to non-PEPFAR countries over time for any of these measures, for men or women, although there was a trend towards a lower number of reported sexual partners for men in PEPFAR and non-PEPFAR countries.
Further analysis will examine whether higher per capita funding had any effect, although Lo said that preliminary analysis showed no impact of funding intensity.