The United States launched the President's Emergency Fund for AIDS Relief, also known as PEPFAR, in 2004 in an effort to reduce HIV transmissions and teen pregnancies by encouraging men and women to limit their number of sexual partners and hold off on their first sexual experience. It didn’t take long before these recommendations were met with criticism.

Researchers from the Stanford University School of Medicine have now confirmed in a study published in Health Affairs that the $1.4 billion the government has spent on programs that promote abstinence and fidelity has been ineffective at changing sexual behavior and reducing the transmission of HIV.

President George W. Bush launched the PEPFAR to strengthen global AIDS treatment and prevention, especially in 15 countries with high rates of sexually transmitted disease. The program initially required that one-third of its funds go directly to abstinence and so-called “be faithful” initiatives. Experts argued focusing on these prevention methods would only undervalue more effective options, such as condom use, male circumcision, and ways to prevent mother-to-child transmission.

When President Barack Obama took office, he ended the one-third requirement. Funds allotted to abstinence and fidelity programs dropped from $260 million in 2008 to $45 million in 2013.

“If you look at where funds from PEPFAR are being distributed you can see noticeable improvements in certain measures of health,” Nathan Lo, a Stanford medical student and lead author of the study, told Medical Daily. “But if you look to when one-third of funds were spent on these abstinence initiatives, it wasn’t hard to see something wasn’t working.”

Lo and his colleagues analyzed the medical records of 345,000 women and 132,000 men from 14 of the sub-Saharan African countries targeted by the PEPFAR and eight nearby countries where the fund didn’t spend its money. The data, taken from 1998 to 2013, revealed no difference in the number of sexual partners or in teenage pregnancy rates among people living in the two country groups. The average woman in PEPFAR countries was four months older at the age of her first sexual intercourse, and there was no age difference among men.

“Abstinence- [and fidelity-] based programs have very little evidence to back them up,” Lo said. “We believe our research shows that funds would be better spent on initiatives that are strongly evidence based. That can include programs that increase condom use and ways to reduce transmission between an HIV-positive mother and her child.”  

The research team did identify one factor that was closely related to sexual behavior in women: education level. Women with at least a primary school education had significantly lower rates of high-risk sexual behavior compared to those without a formal education. Women with higher education levels were more likely to be cautious when it came to picking their sexual partners and also knew which behaviors were risky.

The PEPFAR hasn’t been a complete failure, however. In 2012, this same research team conducted a similar study that examined health and survival information taken from surveys in which 1.5 million men and women living in 27 African countries, including nine countries with a PEPFAR program, talked about their personal and family health. All-cause mortality rates were around 20 percent lower in PEPFAR countries. This seemed to be a fortuitous finding seeing as foreign aid has been met with resistance from both policy experts and the countries receiving the aid.

“We were surprised and impressed to find these mortality reductions,” Dr. Eran Bendavid, an assistant professor of medicine at Stanford, said when the 2012 study came out. “While many assume that foreign aid works, most evaluations of aid suggest it does not work or even causes harm. Despite all the challenges to making aid work and to implementing HIV treatment in Africa, the benefits of PEPFAR were large and measureable across many African countries.”

The Stanford research team has now started a conversation with PEPFAR in order to see where funds are best spent. They are confident their work shows the importance of investing in alternative evidence-based programs for HIV prevention. Behavioral change is not an easy task and it will take a lot more than a billboard and a doctor telling young people to wait.

Source: Lo N, Bendavid E, et al. Abstinence Funding Was Not Associated With Reductions In HIV Risk Behavior in Sub-Saharan Africa. Health Affairs. 2016.