A federal program for HIV prevention in sub-Saharan Africa has failed to demonstrate reduction in risk through abstinence and fidelity education, according to a study released Monday from Stanford University researchers.
Among its other efforts, the program, known as PEPFAR, or the President’s Emergency Fund for AIDS Relief, supports initiatives that teach abstinence, reduction in sexual partners and delay in the first sexual experience. It’s intended to reduce the risk of HIV infection and also cut the number of teen pregnancies.
More than $1.4 billion has been invested in these programs since PEPFAR’s inception in 2004 to 2013, the study said. But an examination of the behavior of nearly 500,000 people in 22 countries failed to find any evidence that the education program had made any difference in changing behavior, the study found.
So the study suggested PEPFAR should shift funding to other initiatives that have shown more effectiveness.
“These results suggest that alternative funding priorities for HIV prevention may yield greater health benefits,” the study said. It was published in the journal Health Affairs. When published online, the study can be found at http://j.mp/pepfar1.
“Overall we were not able to detect any population-level benefit from this program,” Nathan Lo, a Stanford MD/PhD student and lead author of the study, said in a Stanford statement.
For example, the study found no evidence for a significant change in the age of first intercourse in countries with PEPFAR abstinence programs compared to those without them.
“Similarly, we were unable to detect an effect of PEPFAR abstinence and faithfulness funding upon the proportion of teenage pregnancy for people living in PEPFAR-funded countries,” the study stated.
PEPFAR said that it responds to science in pursuing its mission of curbing HIV transmission.
“To fulfill this mission, PEPFAR has continually evolved its approach to, and investments in, HIV prevention based on the latest scientific evidence and lessons learned from applying this evidence in programs,” the PEPFAR statement said.
“Current prevention science demonstrates that a combination package of evidence-based behavioral, biomedical, and structural prevention interventions, tailored to the populations and geographic areas with the greatest burden, is most effective in addressing the epidemic.”
The researchers credited PEPFAR with receiving their findings with an open mind.
Some of PEPFAR’s programs have had great success. For example, a 2012 study published in JAMA found PEPFAR’s activities were associated with saving about 740,000 adult lives from 2004 to 2008 in the geographical areas it was most active.
PEPFAR was originally mandated to spend one-third of its prevention funding on abstinence efforts when it was formed in 2004 under the presidency of George W. Bush. President Barack Obama eliminated the requirement after he assumed office in 2009. However, some funding has continued to go to these programs.
Abstinence and fidelity funding fell to $67 million in 2012 and $45 million in 2013, the study said. Researchers say the program should go further and consider phase it out entirely in favor of other initiatives.
“While PEPFAR’s present commitments to abstinence and faithfulness programs are smaller than its historical support for them, recent funding remains substantial,” the study stated. “Investing in prevention programs with established records of effectiveness could promote population health improvements.”
Eran Bendavid, an author of the JAMA article and the new study, said in the Stanford statement that behavior-changing efforts need to do more than generate public awareness.
“Changing sexual behavior is not an easy thing,” Bendavid said. “These are very personal decisions. When individuals make decisions about sex, they are not typically thinking about the billboard they may have seen or the guy who came by the village and said they should wait until marriage. Behavioral change is much more complicated than that.”
Stanford medical student Anita Lowe was also a co-author of the study.
The study was funded by the Doris Duke Charitable Foundation and Stanford’s Center on the Demography and Economics of Health and Aging. Stanford’s Department of Medicine also supported the work.