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Rights. Respect. Responsibility.® The Fix the GAP Campaign—Stop U.S. Exportation of Abstinence-Only Programs
The ABCs and HIV Prevention: How the U.S. Government Limits Youth's Access to Health Information
The Real ABCs: Uganda's Success
Abstinence
Be Faithful
Use Condoms
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During the late 1980s, Uganda adopted a comprehensive public health strategy to stop the spread of AIDS. According to the U.S. Agency for International Development, Uganda implemented this strategy—Abstinence, Be faithful, use a Condom—along with: 1) increased leadership from high-ranking government officials, led by President Museveni; 2) decentralized and personalized efforts to change behaviors; 3) policy and legal changes elevating the status of women and youth and addressing stigma and discrimination; 4) cooperation of communities of faith; 5) confidential, voluntary HIV counseling and testing; 6) condom social marketing within an aggressive media campaign; and 7) STI prevention and control. This comprehensive approach led to a drop in Uganda's HIV prevalence, from 15 percent in 1991 to five percent in 2001.[1]
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A report from UNFPA about Uganda's success indicates that young people have benefited from the comprehensive approach. "Evidence suggests that many young people are changing their behaviors … young people abstain, have their sexual relations later, and have fewer sexual partners than they did a few years ago, and those who engage in sexual activity are more likely to use condoms."[2]
How the U.S. Government Spells ABC
For youth—Abstinence-only-until-marriage
For married people—Be faithful
For people in 'high risk' groups—Condom use |
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In 2002, the U.S. government launched a $15 million campaign to fight global HIV and AIDS. Conservative politicians and organizations twisted the comprehensive, Ugandan ABC strategy into a stratified policy, based on ideology rather than science. As such, under the President's Emergency Plan for AIDS Relief (PEPFAR), young people are to receive information only about abstinence. |
What PEPFAR Really Says
For young people who are not yet sexually active, abstinence until marriage will be the key approach.[3]
[PEPFAR / APS No. M/OP-04-812, p. 8]
For youth and young adults who have previously initiated sexual activity but are not yet married, increased 'secondary abstinence until marriage' will be the key approach.[3]
[PEPFAR / APS No. M/OP-04-812, p. 8]
Four Misguided Assumptions Underlying PEPFAR's Approach for Youth
Assumption 1—The majority of adolescents in PEPFAR's focus nations (including 12 nations in sub-Saharan Africa) are not sexually active.*[3,4]
Fact: In fact, more than 11 million young people in PEPFAR's focus countries are sexually active. For example in sub-Saharan Africa, the median age for first sex among young women is 16.5 in Kenya; 16.6 in Botswana, Tanzania, and Uganda; and 16.8 in Zambia. The median age for first sex among young men is 16.8 in Tanzania, 17.1 in Kenya, and 18.3 in Uganda. PEPFAR does little to address the sexual health needs of these youth.[4,5]
Assumption 2—Adolescents, whether or not they are currently sexually active, can be persuaded to practice abstinence—without exception—until marriage.*[3,4]
Fact: A study of virginity pledge programs found that pledges can help delay the onset of sex for some youth in some circumstances. Yet when youth break their pledge, they are significantly less likely than non-pledgers to use contraception or condoms, putting them at 35 percent higher risk of pregnancy and significantly greater risk for HIV.[6] Further, once pledgers begin to have sex, they are as likely to experience STIs because they are far less likely to use condoms; they are also less likely to seek STI testing and treatment than non-pledgers.[7]
Assumption 3—Risk elimination (abstinence) is the most effective approach for reducing the spread of HIV infection among youth. Risk reduction strategies (such as condom use) should be targeted only at "high risk" groups (such as sex workers and injected-drug users) and are not appropriate for youth and other groups.*[3,4]
Fact: There is no evidence that abstinence-only-until-marriage programs work. In fact, studies by organizations such as the World Health Organization, UNAIDS, the Institute of Medicine, and the American Medical Association show that comprehensive sexual health education programs—which provide accurate information about abstinence and about risk reduction, such as condom use—help youth delay the onset of sexual intercourse and also help sexually active young people protect themselves from pregnancy, HIV, and other STIs.[8,9,10,11,12] The Centers for Disease Control & Prevention and the U.S. National Institutes of Health agree that correct and consistent condom use is highly effective in preventing HIV transmission.[13,14]
Assumption 4—Marriage is a protective factor against HIV infection.*[3,4]
Fact: More than 51 million young women and girls, under the age of 18, are already married. International Center for Research on Women reports that married girls in Kenya and Zambia are more likely to be HIV-positive than their sexually active, unmarried counterparts, because their husbands are often 10 or more years older than the girls and may already be infected with HIV. Moreover, young married women seldom have power within marriage to protect themselves and are seldom able to refuse sex or negotiate condom use.[15]
Conclusion
In a world where adolescents are at high risk for contracting HIV and other STIs, there is a need to arm all young people with as much information as possible. Evaluations show that education which includes information both about abstinence AND contraception is the most effective in delaying onset of first sexual intercourse and in ensuring that young people protect themselves when they do become sexually active. Studies clearly show that neither provision of information nor access to contraception and condoms increases sexual activity among youth.
Respect young people's right to information and services!
*Advocates for Youth gratefully acknowledges the Center for Health and Gender Equity for analyzing PEPFAR's underlying assumptions in the Center's Debunking the Myths in the U.S. Global AIDS Strategy: An Evidence-Based Analysis, 2004.
Written by Kayley Harrington, Coordinator, International Youth Leadership Council, Advocates for Youth, ©2004
References:
- Hogle JA, editor. What Happened in Uganda? Declining HIV Prevalence, Behavior Change, and the National Response. [Project Lessons Learned Case Study] Washington, DC: U.S. Agency for International Development, September 2002, (pp. 3-8).
- United Nations Population Fund. State of World Population, 2003: Making 1 Billion Count: Investing in Adolescents Health and Rights. New York, NY: UNFPA, 2003, (p. 31).
- U.S. Agency for International Development. Annual Program Statement: HIV/AIDS Prevention through Abstinence and Healthy Choices for Youth: President's Emergency Plan for AIDS Relief. [APS No. M/OP-04-812] Washington, DC: USAID, March 11, 2004, (p. 8).
- Center for Health and Gender Equity. Debunking the Myths in the U.S. Global AIDS Strategy: An Evidence-Based Analysis. Takoma Park, MD: The Center, March 2004, (p. 5).
- United Nations. World Population Prospects: The 2002 Revision, Volume II: Sex and Age. New York, NY: UN, 2003, [used with USAID acknowledged percentages of unmarried adolescents in sub-Saharan Africa who are sexually active prior to age 20, citation #3, p. 9]
- Bearman PS, Brückner H. Promising the future: virginity pledges and first intercourse. American Journal of Sociology 2001; 106:859-912.
- Bearman PS, Brückner H. The Relationship between Virginity Pledges in Adolescence and STD Acquisition in Young Adulthood. Presentation at the National STD Prevention Conference, Philadelphia, PA, March 9, 2004.
- Baldo M et al. Does Sex Education Lead to Earlier or Increased Sexual Activity in Youth? Presented at the IXth International Conference on AIDS, Berlin, 6-10 June 1993. Geneva, Switzerland: World Health Organization, 1993.
- UNAIDS. Impact of HIV and Sexual Health Education on the Sexual Behaviour of Young People: A Review Update. [UNAIDS Best Practice Collection, Key Material] Geneva, Switzerland: UNAIDS, 1997.
- UNAIDS. Young People and HIV/AIDS: Opportunity in Crisis. Geneva, Switzerland: UNAIDS, 2002.
- Institute of Medicine, Committee on HIV Prevention Strategies in the United States. No Time to Lose: Getting More from HIV Prevention. Washington, DC: National Academy Press, 2001
- American Medical Association, Council on Scientific Affairs. Report of the Council on Scientific Affairs [Action of the AMA House of Delegates 1999 Interim Meeting, CSA Report 7-I-99] Chicago, IL: AMA, 1999.
- Centers for Disease Control & Prevention. Condoms and Their Use in Preventing HIV Infection and Other STDs. Atlanta, GA: CDC, 1999.
- National Institutes of Health. Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease (STD) Prevention: Workshop Summary, June 12-13, 2000, Herndon, Virginia. Rockville, MD: U.S. Dept. of Health & Human Services, 2001.
- Mathur S, Greene M, Malhotra A. Too Young to Wed: The Lives, Rights, and Health of Young Married Girls. Washington, DC: International Center for Research on Women, 2003, p.9.
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