Abstinence in HIV prevention: science and sophistry
Authors: Chika Edward Uzoigwe, Luis Carlos Sanchez Franco
Journal: The Lancet Global Health (2016)

Kent Buse and colleagues (September, 2016)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 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.2US CDCHIV/AIDS: prevention.http://www.cdc.gov/hiv/basics/prevention.htmlDate: 2016Google Scholar The fact that this message appears neither popular nor palatable cannot justify health-care professionals failing to praise the veracity of this message. Indeed it should encourage all involved in health-care promotion to re-evaluate the manner in which the message is delivered. For example, Buse and colleagues1Buse 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 clearly identify a problem, in some areas, where the fidelity and abstinence models of HIV prevention are expressed in pejorative terms relating to abuse and the risks of sex. The US Centers for Disease Control and Prevention (CDC) on their information website2US CDCHIV/AIDS: prevention.http://www.cdc.gov/hiv/basics/prevention.htmlDate: 2016Google Scholar place abstinence as the first practice to reduce the risk of HIV transmission. Furthermore, their HIV risk reduction tool also emphasises the primacy of abstinence in HIV prevention.3US CDCHIV: risk reduction tool.http://www.cdc.gov/hivrisk/decreased_risk/abstinence.htmlGoogle Scholar Abstinence encompasses a range of behaviours including delaying sexual debut and reducing number of sexual partners. The tool states that “not having sex is the best way to prevent getting or transmitting HIV”. A fundamental tenet of disease prevention in epidemiology is risk avoidance. The CDC estimates that every day in the USA in excess of 3200 people younger than 18 years smoke their first cigarette. Furthermore, every day approximately 2100 youths and young adults who have been occasional smokers become daily cigarette smokers.4US CDCSmoking and tobacco use: fast facts.http://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/Google Scholar However, the primary message from the CDC is single-minded, uncompromising, and unequivocal that smoking kills and smoking cessation results in substantial health benefits.5US CDCTips from former smokers.http://www.cdc.gov/tobacco/campaign/tips/index.htmlGoogle Scholar Evidence that this message does not dissuade the annual 1·2 million new smokers could never justify abdicating our professional responsibility to highlight behaviour and practices that engender low risk and those that attract high risk. The same would apply to diet, exercise, and sexuality. A sequitur from the logic presented by Buse and colleagues1Buse 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 would be that doctors telling people that doughnuts and high-sugar drinks are unhealthy does not deter people from eating such foods, so doctors should abstain from promoting this message as a core aim in healthy eating.6US CDCOverweight and obesity: childhood overweight and obesity.http://www.cdc.gov/obesi ty/childhood/Google Scholar The 2016 WHO guidance7WHOConsolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection.http://apps.who.int/iris/bitstream/10665/208825/1/9789241549684_eng.pdf?ua=1Date: 2016Google Scholar promotes pre-exposure prophylaxis for all populations with an incidence of HIV above three per 100 person-years. This guidance is, some ways, an indictment on the promotion of condoms in HIV prevention. However, WHO does not retract its message regarding the use of condoms. The authors undermine abstinence and fidelity, and yet remain taciturn on the efficacy and role for condoms in health promotion. The popularity or unpopularity of condoms does not deflect the fact that this barrier method of contraception reduces the risk of HIV transmission. The same applies to abstinence and fidelity. To argue otherwise can only be sophistry. As health-care professionals, it is important that we communicate responsible messages rather than popular ones. We declare no competing interests. A 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 AccessAbstinence 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 Access