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US PEPFAR abstinence and faithfulness funding had no impact on sexual behaviour in Africa
Keith Alcorn, 2015-02-26 23:50:00
Nearly US$1.3 billion 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. The preliminary findings were presented by Nathan Lo of Stanford
University School of Medicine at the Conference on Retroviruses and Opportunistic Infections (CROI 2015) in Seattle, USA, on Thursday.
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 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 $200
million a year in 2008, but declined to around $50 million 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
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 Nathan Lo said that preliminary analysis
showed no impact of funding intensity.