Delaying a young person’s sexual debut, or at least the age at which they start having full intercourse, could be a very effective HIV prevention measure in certain populations.

In the developing world young women are much more vulnerable to HIV than young men. In southern Africa, for instance, HIV prevalence among young women ages 15-24 is three times higher than among young men, and among under-20s up to ten times higher (UNAIDS, 2004). This is attributed partly to culture – with a pattern of older men seeking out younger women for sex – but also partly to nature; the immature genital tract of young women is more susceptible to HIV and other STIs.

One population among whom delayed debut of intercourse would serve to reduce HIV infections is young gay men.

In the 2002 Gay Men’s Sex Survey Out and About (Hickson 2003), the authors comment on the finding that the median sexual debut age of young gay men is 16 and the date of first anal intercourse is 17:

“The median age of first heterosexual sex among the male population in the UK is 14 years and median age of first vaginal intercourse is 18. This suggests that gay men have to wait longer before starting to experience sex with men than their heterosexual counterparts do with women, but proceed to intercourse quicker. This is congruent with gay men having been denied opportunities to ‘date’ or ‘court’ while a teenager and being left to enter the adult world of sexuality with little practice, support or guidance.”

Unfortunately, lesbians and gay men are largely excluded from abstinence education programmes – explicitly so in the case of ‘abstinence only till marriage’.

Another population that in some cases appears to be practising abstinence as an HIV prevention method is HIV-positive people. One US survey (Weinhardt 2004), for instance, found that 18.5 per cent of gay men and 26 per cent of heterosexual men and women had not had sex in the three months prior to the survey. Although much of this lack of a sex life will be due to illness, stigma or fear of rejection, some individuals with HIV have taken a willed choice to remain sexually abstinent in order not to pass on their HIV. This appears to be particularly the case with women. The Padare Project (Chinouya 2003), for instance, a survey of HIV-positive Africans living in London, found that while only 10 per cent of men had not had sex in the pervious four weeks, among women the proportion rose to one-third.

Even some positive gay youth appear to be trying abstinence, in the absence of any encouragement to do so. A survey of HIV-positive gay men aged 15-24 in Los Angeles (Lightfoot 2005) found that 12 per cent of this group had had no sex with anyone in the three months preceding the study.

Does encouraging abstinence work? And does it lead to lower HIV incidence? The data are contradictory, and clouded by differing interpretations of the data.

One study (Bessinger 2003) found that the proportion of urban young women aged 15-19 in Uganda who said they had ‘never had sex’ increased from 44 to 60 per cent between 1990 and 2000, with an even sharper increase in young men from 33 to 66 per cent. The same study found similar declines in Zambia but not in Zimbabwe or among young women in Cameroon and Kenya.

However another study (Wawer 2005) from the rural province of Rakai, Uganda found that abstinence rates in teenagers had declined from 60 to 50 per cent in women and 32 to 28 per cent in men between 1990 and 2002. The same study found that a decline in HIV prevalence from 17.6 to 11.4 per cent during the same period was largely due to more people dying of AIDS than becoming infected with HIV. Rakai has a mature epidemic, being the first district of Uganda from which AIDS was reported, in 1982.

In the USA the Clinton administration was the first to set aside $50 million a year specifically for abstinence education, though the Christian Education Centre had first mooted abstinence education as a way of reducing HIV and STIs in 1987 and programmes such as True Love Waits had been running since 1992.

By 2005 under George W Bush this money had risen to $167m, with an 18.5 per cent increase promised for 2006, and with no comparative funding set aside directly for comprehensive, non abstinence-based sex education in schools. However conservative think-tank the Heritage Foundation (Pardue 2004) said this was still only one-twelfth the money spent on all condom provision and comprehensive sex education, and that a large proportion of the federal money was in fact being spent by ‘abstinence plus’ programmes which taught abstinence as the preferred option in a comprehensive sex education package.

Whether these programmes have made any difference is also up for interpretation. One undisputed fact is that the teenage pregnancy rate – seen as an indicator of STI rates –declined in the USA during the 1990s from 117 per 1,000 in 1990 to 84 per 1,000 in 1999, and is now lower than the overall UK rate though it is still five times the rate in the Netherlands.

The national rate declined by 27 per cent (Haddock 2005) – but in California, which is the sole state to have refused federal funds for abstinence-only education, it fell by 40 per cent, and the national rate has not declined further since 2000.

There is no definitive answer as to whether abstinence-only programmes will impact on HIV incidence in American youth.

The most rigorous published review to date (Kirby 2001) of 28 sex education programs in the United States and Canada aimed at reducing teen pregnancy and STIs, 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. Furthermore, these three programs did not reduce the frequency of sex or the number of partners among those students who had ever had sex.

However, this same review found that nine abstinence-plus programmes (meaning abstinence education as part of comprehensive sex education) showed efficacy in delaying sexual debut, as well as reducing the frequency of intercourse and increasing condom use once sex began.

The largest study so far undertaken specifically of abstinence-only programmes (Bearman 2005) also suggests that while they may significantly delay the age of sexual debut, the long-term effect on sexual health is neutral.

The study interviewed 20,000 teenagers aged 12-18 in 1995, and again in 1997 and 2002. At this point 11,550 of them also provided a urine sample so researchers could find any evidence of STI infections.

One in five teenagers said they had taken a virginity pledge. Despite this, 61per cent of ‘consistent’ pledgers had had sex before marriage or before the final 2002 interviews.

The study did find that youth who took abstinence pledges started having sexual intercourse on average 18 months to two years later than youth who did not – though without a proper longitudinal study with baseline attitudes measured, it’s impossible to say whether they would have been the kind of young people who would have delayed sex anyway.

The study authors commented: “Pledgers have fewer partners than non-pledgers. Whereas the typical non-pledger male has had 2.4 partners, male pledgers have 1.5 partners on average (p < .0009). The same pattern holds for females as well, 2.7 for non-pledgers and 1.9 for pledgers (p <.0009).

“Nor are pledgers exposed to STI risk for as long as non-pledgers. The average number of years of sexual activity, or time of exposure, is shorter for pledgers than for others. Consistent pledgers were sexually active for an average of 4.2 years, compared with non-pledgers with 5.9 years (p < .0009). Thus, with respect to both the number of partners and cumulative exposure, pledgers are at lower risk to acquisition of an STI than non-pledgers.”

However the same study found that ‘pledgers’ were one-third less likely to use contraception (barrier or otherwise) when they did have sex than ‘non-pledgers’. It found that pledgers were slightly but significantly less likely to use a condom at first sex (55 per cent versus 60 per cent condom use, p= <018). And teenagers’ STI rates once they married were the same regardless of whether they had had premarital sex.

It also found that there was evidence that teenagers who took abstinence pledges were “technically” avoiding loss of virginity by having more oral and anal sex. Just two per cent of non-pledgers reported having no vaginal sex but having oral sex: in pledgers the proportion was 13 per cent.

More worryingly, although the absolute figures were small, more pledgers had anal sex as an alternative to vaginal sex too: 1.2 per cent of pledgers and 0.7 per cent of non-pledgers.

Another survey, (Goodson 2004) of five abstinence-only programmes from 59 schools in Texas, which interviewed 726 11-17 year olds, found that abstinence-only education apparently made no difference to the proportion of teenagers who were sexually active. It found that 23 per cent of year 9 (14 year-old) girls and boys were sexually active before attending an abstinence programme. Afterwards, 28 per cent of girls were sexually active, and when boys were asked a year later at age 15, 39 per cent were active. Other programmes have reported even more substantial increases in sexual activity after programmes, indicating that they have made little or even a negative difference to the natural tendency of more teenagers to start having sex as they get older.

The supporters of abstinence programmes, however, including the Heritage Foundation (Rector 2002), pointed to studies which found that at least 10 programmes had produced success, by some measures, though in some cases this was more to do with changing teenagers’ attitudes towards abstinence than their actual behaviour. It did find, among other things, a steeper decrease in the teenage pregnancy rate in Monroe County, New York, where an abstinence-only programme called ‘Not Me, Not Now’ had been operating, compared with surrounding non-abstinence-only counties. It found that a programme in Little Rock, Arkansas “reduced the sexual activity rate of girls from 10.2 to 5.9 per cent and from boys from 22.8 to 15.8 per cent.” And it found that 14 year-old boys who had not attended a programme in Georgia were three times as likely to have begun having sex by the end of eighth grade as boys who had attended it.

However although abstinence programmes may reduce rates of sexual activity, many do so by spreading disempowering and negative messages about sex and condoms.

The Heritage Foundation document quoted above (Rector 2002) documents significantly higher rates of depression and suicide in teenagers who have sex versus teenagers who don’t, while failing to establish the direction of causation: does sex make teenagers depressed, or do depressed teenagers turn to sex for comfort or due to a history of sexual abuse?

And the fact that condoms prevent 85 per cent of HIV infections if used consistently, and 30 per cent of herpes infections (because herpes can be transmitted through touch) is used as evidence that condoms are not a ‘safe’ protection method against HIV and that they ‘never or rarely’ prevent herpes. This led to pressure on the US Centers for Disease Control and Prevention (the CDC) to take down temporarily from its website information on the effectiveness of condoms, and was the spur to various legislative changes, such as the State of Louisiana withdrawing all state-financed condom distribution in 2004.

Clearly, abstinence or at least delayed sexual debut could prevent a lot of HIV and STI infections in younger people if it was ‘used properly’ as a strategy, but equally clearly the evidence we have so far points to it being used more inconsistently than condoms.

Mindful of public controversy about the amount of money spent on abstinence-only programmes, the US government is currently conducting a large survey of their effectiveness.

Meanwhile in Africa, the lobbying group Human Rights Watch (Human Rights Watch, 2005) criticised an apparent policy shift towards abstinence-only programmes, saying that the Ugandan Government had removed critical HIV information from primary school curricula, including information about condoms, safer sex and the risks of HIV in marriage. Uganda’s Minister of State for Primary Health Care was quoted as saying: “As a ministry, we have realized that abstinence and being faithful to one’s partner are the only sure ways to curb AIDS.  From next year, the ministry is going to be less involved in condom importation but more involved in awareness campaigns; abstinence and behaviour change.”

Uganda’s first lady, Janet Museveni, leads an abstinence programme called the National Youth Forum, describing her approach as “a blend of African and Christian values.” However a spokesman for her husband, President Yoweri Museveni, said the government was merely being consistent in advocating for it’s multi-pronged ‘ABC’ strategy against AIDS: “Those who are sexually active should be faithful to their partners, others who are single should abstain until marriage, and those who cannot abstain should use condoms.”

There has certainly been an increase in the age of sexual debut in Uganda – see chart below – and this may have contributed to reports of declining HIV incidence (see ‘Being faithful’ below). But the sharpest decline happened in the mid-90s, long before abstinence-only as an approach had been adopted in this country, but around the time the HIV epidemic was maturing and large numbers of family members were dying. The fear of death may be a greater incentive to abstinence than exhortations to stay ‘pure’.

(The Uganda charts in this section are all from “What Happened in Uganda? Declining HIV Prevalence, Behavior Change, and the National Response”, Edited by Janice Hogle, USAID, 2002.)

References

Bearman, P and Brückner, H. After the promise: the STD consequences of adolescent virginity pledges. Journal of Adolescent Health, 36(4): 271-278, 2005.

Bessinger Ret al. Sexual Behavior, HIV, and Fertility Trends. A Comparative Analysis of Six Countries. Phase I of the ABC Study. Washington, DC: U.S. Agency for International Development, Measure Evaluation, 2003.

Chinouya, M. & Davidson, O. The Padare Project: Assessing health-related knowledge, attitudes and behaviours of HIV-positive Africans accessing services in north central London. African HIV Policy Network, February 2003.

Goodson P et al. Abstinence education evaluation phase 5: technical report. Department of health and kinesiology, Texas A&M University: 170-172. College Station, Texas, 2004.

Haddock, Vicki. Key to Sex Education: discipline or knowledge – advocating abstinence and safe sex may both cut pregnancies. San Francisco Chronicle, May 22, 2005.

Hickson F et al. Out and About: Findings from the United Kingdom Gay Men’s Sex Survey 2002. Sigma Research, 2003.

Hogle J. What Happened in Uganda? Declining HIV Prevalence, Behavior Change, and the National Response, USAID, 2002.

Human Rights Watch. The Less They Know, the Better: Abstinence-Only HIV/AIDS Programs in Uganda. Human Rights Watch. See http://hrw.org/reports/2005/uganda0305/index.htm.%20march%202005.

Kirby D. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy. Washington D.C. The National Campaign to Prevent Teen Pregnancy, 2001

Pardue Melissa G. et al. Government Spends $12 on Safe Sex and Contraceptives for Every $1 Spent on Abstinence. Heritage Foundation backgrounder #718. See http://www.heritage.org/Research/Family/bg1718.cfm 2004.

Rector Robert E. The effectiveness of abstinence education programs in reducing sexual activity among youth. Heritage Foundation backgrounder #1533. See http://www.heritage.org/research/family/bg1533.cfm.%202002.

UNAIDS. AIDS Epidemic Update. See http://www.unaids.org/html/pub/gcwa/jc986-epiextract_en_pdf.pdf , December 2004.

Wawer MJ et al. Declines in HIV Prevalence in Uganda: Not as Simple as ABC. 12^th Conference on Retroviruses and Opportunistic Infections, Boston, abstract LB272005, 2005.

Weinhardt L et al. HIV Transmission Risk Behavior among Men and Women Living with HIV in 4 Cities in the United States. JAIDS 36(5): 1057-1066, 2004.