A farewell to abstinence and fidelity?
Authors: Kent Buse, Mikaela Hildebrand, Sarah Hawkes
Journal: The Lancet Global Health (2016)

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).1United Nations General AssemblyPolitical Declaration on HIV and AIDS: on the fast-track to accelerate the fight against HIV and to end the AIDS epidemic by 2030 (A/70/52).http://www.hlm2016aids.unaids.org/wp-content/uploads/2016/06/2016-political-declaration-HIV-AIDS_en.pdfDate: June 7, 2016Google Scholar 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.2WHOAdolescent pregnancy—fact sheet.http://www.who.int/mediacentre/factsheets/fs364/enDate: September, 2014Google Scholar For more than 30 years, many sexual health education programmes for young people have promoted abstinence and fidelity as prevention strategies against HIV, sexually transmitted infections, and teenage pregnancy. Long associated with core values of many of the world's religions, these ideas are, nonetheless, relative newcomers to the lexicon of public health interventions. The ABC approach—abstinence, be faithful, correct and consistent condom use—was adopted as a politically expedient way to tackle a public health problem while promoting so-called family values. In the USA, funding for abstinence-only until marriage programmes began in the 1980s under the Reagan administration, reached its zenith in the early 2000s under George W Bush,3Sexuality Information and Education Council of the United StatesA history of abstinence-only-until-marriage programs.http://www.siecus.org/index.cfm?fuseaction=page.viewpage&pageid=1340&nodeid=1Google Scholar and was fully rescinded under Barack Obama in 2016.4WITW StaffPresident Obama cuts funding for all abstinence-only sex education. New York Times, Feb 18, 2016.http://nytlive.nytimes.com/womenintheworld/2016/02/18/president-obama-cuts-funding-for-all-abstinence-only-sex-educationGoogle Scholar Abstinence offered political and religious groups a convenient narrative with which to confront the epidemic. Indeed, the storyline was so strong that in 2003, the US President's Emergency Plan for AIDS Relief (PEPFAR) made its AIDS funding contingent on adoption of the ABC approach. Previous PEPFAR guidelines5PEPFARABC guidance #1: for United States Government in-country staff and implementing partners applying the ABC approach to prevent sexually-transmitted HIV infections within the President's Emergency Plan for AIDS Relief. Office of the US Global Aids Coordinator.http://www.state.gov/documents/organization/57241.pdfGoogle Scholar specified that funds could be used to deliver messages on abstinence until marriage and being faithful in school settings to 10–14 year olds, but condoms could not be distributed in or out of school to this age group. At country level, these approaches have had a clear effect. In Lesotho, a country with an HIV prevalence of 23·4% in its adult population, and where correct and consistent knowledge about HIV prevention is 35% among young people,1United Nations General AssemblyPolitical Declaration on HIV and AIDS: on the fast-track to accelerate the fight against HIV and to end the AIDS epidemic by 2030 (A/70/52).http://www.hlm2016aids.unaids.org/wp-content/uploads/2016/06/2016-political-declaration-HIV-AIDS_en.pdfDate: June 7, 2016Google Scholar a 2014 curriculum review found that “sexuality is presented in an entirely negative light through focusing on sexual abuse, the need to abstain, and the risks of sex”.6UNESCOYoung people today. Time to act now. UNESCO, Paris2013http://youngpeopletoday.net/wp-content/uploads/2014/08/SummaryReport-English.pdfGoogle Scholar Although not detracting from everyone's right to exercise their individual freedom of religion, the evidence in favour of positive behaviour changes as a result of promotion of abstinence and fidelity—rather than evidence-informed comprehensive sexuality education—is highly questionable.7Fonner VA Armstrong KS Kennedy CE O'Reilly KR Sweat MD School based sex education and HIV prevention in low- and middle-income countries: a systematic review and meta-analysis.PLoS One. 2014; 9: e89692Crossref PubMed Scopus (166) Google Scholar Indeed, The Lancet's Commission on Adolescent Health and Wellbeing8Patton 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 (1543) Google Scholar reported finding “high-quality evidence that abstinence-only education is ineffective in preventing HIV, incidence of sexually transmitted infections, and adolescent pregnancy” whereas there is “high-quality evidence of some benefit” of comprehensive school-based sex education when combined with contraception provision. During UN negotiations for the High-Level Meeting, this body of scientific evidence became too large to ignore. Moreover, a US official acknowledged that the USA's contributions had focused on ineffective interventions: a major study of nearly 500 000 individuals in 22 countries found that large US investments in abstinence and fidelity approaches did not result in any changes in individual behaviour.9Lo NC Lowe A Bendavid E Abstinence funding was not associated with risk reductions in HIV risk behavior sub-Saharan Africa health affairs.Health Aff (Millwood). 2016; 35: 5856-5863Crossref Scopus (28) Google Scholar The US Government position, and that of many other delegations from most regions, was that future investments should be allocated to interventions that are supported by evidence of effectiveness. Predictably, this position met opposition during the negotiations. Many socially conservative Member States, in alliance with the Holy See, argued against the deletion of abstinence and fidelity as core components of effective HIV prevention. They were urged on by actors on the margins who provided delegates with misinformation and spurious arguments in opposition to comprehensive sexuality education. One commonly used argument was that previous UN Declarations on AIDS (in 2001, 2006, and 2011) included abstinence and fidelity, and new scientific evidence should not override received wisdom and intergovernmental compromise. For once, however, empirical evidence painstakingly collected and analysed over many decades trumped ideology. As such, the Political Declaration recognises that young people require access to accurate information and reinforcement of the principles of gender equality and rights if they are to realise a sexually healthy life. Lesotho began promoting these requirements even before the High-Level Meeting confirmed their importance. The southern African country now incorporates positive approaches to gender norms and comprehensive sexuality education that is scientifically accurate, age appropriate, and culturally relevant for 9–15 year olds.10Lesotho Ministry of HealthFollow-up to the 2011 Political Declaration on HIV/AIDS: intensifying our efforts to eliminate HIV/AIDS. Lesotho Country Report.http://www.unaids.org/sites/default/files/country/documents/LSO_narrative_report_2015.pdfGoogle Scholar The severity of the AIDS epidemic should not be underestimated—it is by no means over. The 2016 Political Declaration therefore provides a critical entry point for a rights-based approach for adolescents and young people to realise their sexual and reproductive health goals. With scientific evidence rather than dogma, countries should adopt and implement a progressive agenda to end AIDS and ensure sexual health and wellbeing for all (panel).PanelPolicy agenda for comprehensive sexual health programmes for young people•Update country policy frameworks and abandon abstinence-based and fidelity-based HIV prevention programmes, in consultation with technical agencies•Develop comprehensive sexuality education curricula that include addressing gender-power dynamics to deliver on the sexual health and gender equality targets of the 2030 Agenda for Sustainable Development, and strengthen capacity of teachers to deliver it•Work with teachers' unions, parent associations, and traditional and community leaders to shift community perspectives on comprehensive sexuality education and the delivery of comprehensive sexual and reproductive health programmes in and out of schools•Support advocates, including youth groups, to hold their governments accountable for international commitments made, including in the Political Declaration on HIV and AIDS •Update country policy frameworks and abandon abstinence-based and fidelity-based HIV prevention programmes, in consultation with technical agencies•Develop comprehensive sexuality education curricula that include addressing gender-power dynamics to deliver on the sexual health and gender equality targets of the 2030 Agenda for Sustainable Development, and strengthen capacity of teachers to deliver it•Work with teachers' unions, parent associations, and traditional and community leaders to shift community perspectives on comprehensive sexuality education and the delivery of comprehensive sexual and reproductive health programmes in and out of schools•Support advocates, including youth groups, to hold their governments accountable for international commitments made, including in the Political Declaration on HIV and AIDS We declare no competing interests. The views expressed in this Comment do not necessarily reflect those of UNAIDS. Abstinence in HIV prevention: science and sophistry – Authors' replyIn response to our Comment,1 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 Commission2 and adopted as an appropriate public health response by the UN General Assembly.1 Full-Text PDF Open AccessAbstinence 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 Access