A farewell to abstinence and fidelity? (The Lancet Global Health)

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

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.2

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.3
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in the 1980s under the Reagan administration, reached its zenith in the early 2000s under George W Bush,3 and was fully rescinded under Barack Obama in 2016.4

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 guidelines5 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 cleareff ect. 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,1 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”. 6

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.7

Indeed, TheLancet ’s Commission on Adolescent Health and Wellbeing8 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.9

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.10

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 scientifi c evidence rather than dogma, countries should adopt and implement a progressive agenda to end AIDS and ensure sexual health and wellbeing for all (panel).

*Kent Buse, Mikaela Hildebrand, Sarah Hawkes

UNAIDS, Geneva, Switzerland (KB); Swedish Association for

Sexuality Education, Stockholm, Sweden (MH); and University

College London, London, UK (SH)

busek@unaids.org

We declare no competing interests. The views expressed in this Comment do

not necessarily refl

ect those of UNAIDS.

Copyright © The Author(s). Published by Elsevier Ltd. This is an Open Access

article under the CC BY license.

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