Abstinence in HIV prevention: science and sophistry – Authors' reply
Authors: Kent Buse, Sarah Hawkes, Mikaela Hildebrand
Journal: The Lancet Global Health (2016)

In response to our Comment,1Buse K Hildebrand M Hawkes S A farewell to abstinence and fidelity?.Lancet Glob Health. 2016; 4: e599-e600Summary Full Text Full Text PDF PubMed Scopus (13) Google Scholar Chika Uzoigwe and Luis Sanchez Franco accuse us of sophistry in reporting the best available evidence, which suggests that the promotion of abstinence and fidelity does not prevent HIV, sexually transmitted infections (STIs), or unwanted pregnancies—evidence supported by the findings of a Lancet Commission2Patton G Sawer SM Santelli JS et al.Our future: a Lancet commission on adolescent health and wellbeing.Lancet. 2016; 387: 2423-2478Summary Full Text Full Text PDF PubMed Scopus (1511) Google Scholar and adopted as an appropriate public health response by the UN General Assembly.1Buse K Hildebrand M Hawkes S A farewell to abstinence and fidelity?.Lancet Glob Health. 2016; 4: e599-e600Summary Full Text Full Text PDF PubMed Scopus (13) Google Scholar Uzoigwe and Sanchez Franco fail to grasp a basic distinction in epidemiology between efficacy and effectiveness. Efficacy refers to the effect of an intervention under controlled or ideal conditions, and effectiveness refers to its effect in real-world situations. By way of illustration: driving leads to road traffic injuries. Abstaining from driving would eliminate such injuries—an efficacious intervention. In the real world, where people rely on motorised transport, the use of driver education programmes, seat belts, and other harm-reducing measures is seen as a more realistic approach than abstinence, and offers some proven effectiveness against injuries (although not enough). Uzoigwe and Sanchez Franco present some spurious arguments. They cite tobacco and advocate for abstinence—omitting to mention the absence of any known health benefits from smoking. A better analogy would be nutrition. Several undesirable effects can happen if people eat the wrong foods or too much of the right foods. It is our duty as health professionals not to stop them from eating but to guide them to healthy eating choices. We posit that there are many health benefits from pleasurable and safe sexual experiences, free of coercion, discrimination, and violence.3WHODefining sexual health.http://www.who.int/reproductivehealth/topics/sexual_health/sh_definitions/en/Google Scholar But in the real world there are risks from unsafe sex, including unintended pregnancies, STIs, and HIV. Hence, we support programmes based on evidence to reduce those risks—rather than specious notions of abstinence (for how long?) or reducing the number of sexual partnerships (what would a safe number be exactly?). Comprehensive sexuality education, challenging harmful social norms, the empowerment of young people, and access to condoms and other contraceptives are effective, although not perfect, options. We should ensure that all people, young and old, can enjoy the benefits of positive approaches to sexual health, including sexual relationships—safely and consensually. There exists a wider morality-driven, political project that seeks to limit sexual rights—including prohibiting comprehensive sexuality education, abortion, and same-sex sexual relations.4Hawkes S Buse K Sights set on sexual rights in global culture wars: implications for health.http://globalhealth.thelancet.com/bloggers/sarah-hawkes-kent-buseDate: 2015Google Scholar Once again, we see that ensuring sexual and reproductive health and rights for all requires more than evidence, it requires managing the inherent politics therein.5Buse K Martin-Hilber A Widyantoro N Hawkes SJ Management of the politics of evidence-based sexual and reproductive health policy.Lancet. 2006; 368: 2101-2103Summary Full Text Full Text PDF PubMed Scopus (25) Google Scholar We declare no competing interests. Abstinence in HIV prevention: science and sophistryKent Buse and colleagues (September, 2016)1 make a compelling argument for HIV prevention initiatives to abandon educational interventions based on fidelity and abstinence. This approach is potentially hazardous and antithetical. It is important not to conflate the efficacy of the message with the persuasiveness of the messenger. The evidence is unquestionable that abstinence and fidelity reduce HIV transmission.2 The fact that this message appears neither popular nor palatable cannot justify health-care professionals failing to praise the veracity of this message. Full-Text PDF Open AccessA farewell to abstinence and fidelity?Sex has regularly proven to be a polarising issue for the UN Member States, and the 2016 High-Level Meeting on Ending AIDS on June 8–10 was no exception. The Political Declaration adopted at the meeting addresses the sexual health needs of young people (15–24 years), including adolescents (11–19 years).1 2000 new HIV infections occur among young people every day. HIV is the leading cause of death among adolescents in Africa, and the second-highest cause of death worldwide in this age group . HIV is not their only sexual health concern—globally, 17 million adolescent girls give birth every year, 1 million of them younger than 15 years, and a further 3 million will have an unsafe abortion. Full-Text PDF Open Access