/amfar/Today, nearly 39 million people around the world are living with HIV/AIDS. At the end of 2003, 10 million young people aged 15-24 were living with HIV/AIDS, and the number continues to grow.¹ In the United States, an estimated 850,000-950,000 people are living with HIV/ AIDS, with approximately 40,000 new infections occurring per year. From 2000 to 2003, HIV/AIDS increased by 10 percent among young people in the U.S. aged 15-24.²

These statistics have prompted an expansion of programs aimed at reducing the spread of HIV infection among young people. Among those that are federally funded, the majority are abstinence-only HIV prevention programs.

Growth in Programs

The United States government has been supporting abstinence-only programs to prevent teen pregnancy since 1981. Over the years, such programs have grown to include HIV/AIDS and other sexually transmitted disease (STD) prevention. This trend expanded on an international level with the implementation in 2003 of the President's Emergency Plan for AIDS Relief (PEPFAR), which specifically mandates that one-third of all prevention dollars allocated to 15 focus countries through the program must be earmarked for abstinence-only programs.³

In the domestic arena alone, funding for key federal abstinence-only programs has increased from $80 million in 2001 to $167 million in 2005 (see Figure 1). Given that abstinence-only education has become the cornerstone of the U.S. government's HIV prevention strategy for young people, it is important to assess the scientific evidence of its efficacy in reducing the risk of HIV/AIDS, especially relative to other HIV prevention strategies, such as comprehensive sex education, for which there are no targeted federal programs or funding streams.⁴

Defining Abstinence

There are no uniform or consistent definitions of abstinence-only programs. Currently, two approaches predominate: "abstinence-only" (also called "abstinence-only-until-marriage") and "abstinence-plus" (also called "abstinence-based" or "comprehensive sex education").

Abstinence-only programs emphasize refraining from sexual intercourse until marriage as the safest choice to prevent teen pregnancy and sexually transmitted infection. The primary objective of abstinence-only programs is to delay sexual debut (the onset of sexual intercourse) by providing information, changing attitudes about sex, and improving decision-making skills.^5-9

Federally funded abstinence-only programs in the U.S. must have as their "exclusive purpose, teaching the social, psychological, and health gains to be realized by abstaining from sexual activity," and must teach "that a mutually faithful monogamous relationship in the context of marriage is the expected standard of human sexual activity" and that "sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects," among other requirements. These programs also are prohibited from discussing contraception or STD prevention technologies, such as condoms, except in reference to their failure rates.¹⁰

Under PEPFAR, international programs are expected to "encourage unmarried individuals to abstain from sexual activity as the best and only certain way to protect themselves from exposure to HIV" and other STDs.³

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Abstinence-plus programs strongly encourage abstinence among young people but also provide information about contraception and STD risk reduction. In addition to endorsing delay of sexual debut, abstinence-plus programs aim to increase knowledge, behavioral intentions, and use of contraception and disease prevention methods among those who do become sexually active.^5-8 Some also discuss variation in human sexuality.

Measuring Abstinence

Both abstinence-only and abstinence-plus programs measure a range of knowledge, attitudinal, and behavioral outcomes, including knowledge about HIV/AIDS and other STDs, ability to discuss sexual and relationship matters, perceptions of peer activity and norms, age at first intercourse, number of partners, frequency of sexual activity, and condom use.^5-9,11

However, most abstinence-only and abstinence-plus programs have not been implemented with an experimental design that would allow for rigorous evaluation of their efficacy. Moreover, most have only measured attitudinal, rather than behavioral outcomes. Of those that can be evaluated systematically, the key behavioral outcome assessed is delaying sexual debut, usually by 12 to 18 months.

Summary of the Evidence

Results from systematic reviews (in which the data and outcomes from several studies are analyzed together to obtain an overall finding) are mixed.

• The most rigorous published review to date of 28 sex education programs in the United States and Canada aimed at reducing teen pregnancy and STDs, including HIV, found that none of the three abstinence-only programs that met inclusion criteria for review demonstrated evidence of efficacy for delaying sexual debut.⁶
• Furthermore, these three programs did not reduce the frequency of sex or the number of partners among those students who had ever had sex.⁶
• This same review found that nine abstinence-plus programs showed efficacy in delaying sexual debut, as well as reducing the frequency of intercourse and increasing condom use once sex began.⁶
• A systematic review of the efficacy of AIDS risk reduction interventions for adolescents in the U.S. found that two out of six studies meeting inclusion criteria showed efficacy in postponing sexual debut among virgins and an increase in "secondary" abstinence (return to abstinence) among those who had been sexually active.⁸
• A systematic review of the efficacy of adolescent reproductive health interventions in developing countries found that of the 15 abstinence-plus programs that measured sexual debut, five showed efficacy in delaying sexual debut.⁵
• A review of 11 school-based HIV prevention programs for youth in Africa found that only one program was effective in delaying sexual debut.⁷

Across these reviews, programs were considered generally effective if they reduced one or more behaviors that lead to unintended pregnancy or HIV/STD infection; gave clear messages about sexual activity and contraceptive/condom use; provided accurate basic information about the risks of teen sexual activity; provided activities to address social pressures that influence sexual behavior; modeled and practiced communication, negotiation, and refusal skills; set behavioral goals that were age, culture, and experience specific; and lasted a sufficient length of time.^5-8

These reviews conclude that programs are more likely to be effective in delaying sexual debut if they have an explicit theoretical basis, target younger rather than older youth, build youth development skills, and provide abstinence plus risk reduction information, rather than just an abstinence-only message.

Other relevant data come from the National Longitudinal Study of Adolescent Health, a U.S. government-supported survey of more than 20,000 American young people. Researchers examined the difference between young people who took a pledge to remain a virgin until marriage -- perhaps the most explicit statement of behavioral intentions -- and those who did not, and found that:

• There is no significant difference in STD rates between virginity pledgers and non-pledgers, despite the fact that pledgers tend to postpone sexual debut, have less cumulative exposure to HIV and sexually transmitted diseases, and have fewer sex partners, especially non-monogamous partners.¹¹

Conclusion

In summary, the scientific evidence does not support the U.S government's current policy of making abstinence-only-until-marriage programs the cornerstone of its HIV prevention strategy for young people. Nor does it support the rapid scale-up of resources to promote abstinence-only-until-marriage programs in the U.S. and globally. Rather, the scientific evidence to date suggests that investing in comprehensive sex education that includes support for abstinence but also provides risk-reduction information would be a more effective HIV prevention strategy for young people.

References

1. UNAIDS. 2004 Report on the Global AIDS Epidemic. UNAIDS, 2004.
2. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report.
3. Office of the United States Global AIDS Coordinator. The President's Emergency Plan for AIDS Relief: U.S. Five-Year Global HIV/AIDS Strategy. United States Government, 2004.
4. An evaluation of several federally funded abstinence-only programs under Title V is currently being undertaken by the U.S. Department of Health and Human Services' Office of the Assistant Secretary for Planning (ASPE). Results have yet to be released.
5. Speizer IS, Magnani RJ, Colvin CE. The effectiveness of adolescent reproductive health interventions in developing countries: a review of the evidence. J Adolesc Health 2003;33(5):324-48.
6. Kirby D. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy. Washington D.C.: The National Campaign to Prevent Teen Pregnancy, 2001.
7. Gallant M, Maticka-Tyndale E. School-based HIV prevention programmes for African youth. Soc Sci Med 2004;58(7):1337-51.
8. Kim N, Stanton B, Li X, Dickersin K, Galbraith J. Effectiveness of the 40 adolescent AIDS-risk reduction interventions: a quantitative review. J Adolesc Health 1997;20(3):204-15.
9. Shuey DA, Babishangire BB, Omiat S, Bagarukayo H. Increased sexual abstinence among in-school adolescents as a result of school health education in Soroti district, Uganda. Health Educ Res 1999;14(3):411-9.
10. Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PL 104-193). HHS, Health Resources and Services Administration [HRSA], Maternal and Child Health Bureau, SPRANS Community-Based Abstinence Education Project Grant Program (fact sheet, undated, online at ftp://ftp.hrsa.gov/mchb/abstinence/cbofs.pdf).
11. Bruckner H, Bearman P. After the promise: The STD consequences of adolescent virginity pledges. J Adolesc Health 2005;36(4):271-8.