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CROI 2015: PEPFAR Abstinence and Faithfulness Funding Had No Impact on Sexual Behavior in Africa


Nearly $1.3 billion spent on U.S.-funded programs to promote abstinence and faithfulness had no significant impact on sexual behavior in 14 countries in sub-Saharan Africa, an analysis of sexual behavior data has shown. The preliminary findings were presented by Nathan Lo of Stanford University School of Medicine at the recent 2015 Conference on Retroviruses and Opportunistic Infections (CROI) in Seattle.

[Produced in collaboration with Aidsmap]

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 spent on programs promoting abstinence from sexual relations, delaying sexual activity, and faithfulness to a single partner. Programs supported by this funding stream also promoted reduction in the number of partners. 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, programs have been required to justify to Congress why they spend less than 50% of prevention funding on these programs. Funding for the programs peaked at $200 million in 2008, but declined to around $50 million in 2013, as money has been directed to other measures with stronger evidence of effectiveness.

Programs aimed to delay the age of 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 the funding.

The analysis was designed to determine whether the implementation of abstinence and faithfulness-based prevention programming had had a significant impact on the sexual behaviors it was designed to address.

The researchers looked at trends in sexual behavior 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 8 other African countries -- largely in West Africa -- where PEPFAR funding was not determining the content of prevention campaigns.

By looking at trends in behavior 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 behavior 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 for 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.



NC Lo, A Lowe, and E Bendavid. The Impact of PEPFAR Abstinence and Faithfulness Funding Upon HIV Risk Behaviors in Sub-Saharan Africa. 2015 Conference on Retroviruses and Opportunistic Infections. Seattle, February 23-24, 2015. Abstract 160.