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HIV Prevention Knowledge Base
Behavioral Interventions: Delayed Sexual Debut
I. Definition of the Prevention Area
Delay of sexual debut is an important tactic in HIV prevention among youth, resulting in fewer years at high risk. "Abstinence-only" programs, which promote complete sexual abstinence as the only effective method for preventing unintended pregnancy and sexually transmitted infections including HIV, have not been demonstrated to reduce HIV risk behaviors. Recommended instead are comprehensive sexual education programs that include sex education and information on abstinence, delay of sexual debut, partner limitation, condom use, and contraception.
II. Epidemiological Justification for the Prevention Area
Several national demographic surveys have found a correlation between early onset of sexual activity and higher HIV prevalence among young people, who may not be biologically or psychologically ready for sex. In fact, older age at first sex appears to be one contributing factor in declines in HIV prevalence among youth in sub-Saharan countries with generalized epidemics.
III. Core Programmatic Components
Efforts to delay sexual debut should be incorporated into comprehensive sexual education programs and should begin early, offering age-appropriate messages over time. Comprehensive sexual education programs are typically targeted towards youth and are predominately school-based. Opportunities to reach out-of-school youth, who may be at heightened vulnerability, should be identified as well. Comprehensive programs may include messages that:
- Reinforce positive individual and group norms
- Teach safer sex practices for young people who are already sexually active
- Offer opportunities to practice skills in negotiating for safer sex or refusing sex
- Provide access to condoms.
Several studies show that such programs can help to achieve desired behavior changes without leading to an increase in participants' sexual activity.
IV. Current Status of Implementation Experience
According to a report by the U.S. Institute of Medicine (IOM), effective programs were comprehensive, combining abstinence messages with safer sex education and condom availability. A media campaign in Zambia that conveyed age-appropriate messages to youth suggests that media campaigns can be useful adjuncts to programs encouraging delayed sexual debut as part of a comprehensive sexual education program.
Gender Factors Associated with Sexual Abstinent Behavior of Rural South African High School Going Youth in KwaZulu-Natal, South Africa
Dlamini, S., Taylor, M., Mkhize, N., et al. Health Education Research (2009), Vol. 24 No. 3, pp. 450–60.
The study of ninth-grade students in rural South African high schools investigated the prevalence of sexual abstinence among rural KwaZula-Natal 14- to 20-year-old youth. The study analyzed gender perception about abstinence and motivating factors in abstaining from sex, and found that students who practiced abstinence were more likely to be younger females who also drank less alcohol. Girls who abstained from sex tended to believe that their friends and parents wanted them to abstain; that their friends also abstained from sex; and that abstinence helped them to mature emotionally. Abstaining girls tended to feel more confident than non-abstaining girls about saying no to sex when their partner pressured them. Abstinent boys expressed intentions to abstain from sex until marriage. The authors conclude that programs need to consider developing different abstinence activities for boys and girls. Programs that target and encourage females to abstain should focus on social influences, which include perceptions of friends and parents about abstinence from sex, parental support, and intervening early before the age of sexual initiation. For males, activities should include skills on resisting pressure to have sex and also changing and creating positive attitudes towards sexual abstinence.
Trends in HIV infection: Prevention-related Attitudes and Behaviors among Secondary School Students In Western Uganda
Kilian, A.H., Kipp, W., Jhangri, G.S., et al. Journal of Acquired Immune Deficiency Syndromes (2007), Vol. 44 No. 5, pp. 586–93.
The study tracked western Ugandan youths’ trends specific to HIV and AIDS prevention behaviors between 1995 and 2001. Data were collected annually from schools from three districts using a self-administered questionnaire. A cross-sectional sample of students from these schools was selected each year to obtain a generalized representation of youth in the area. For the study, 15 students were randomly selected. It was found that ever use of condoms increased from the 1995 to 1996 school year to the 2000 to 2001 school year (49 percent versus 73 percent). Abstinence increased more among males than females. During this period, females reported fewer partners compared to their male peers. These positive behavioral changes in regional youth could help explain this group’s reduction of HIV and AIDS prevalence.
Sexual Abstinence, Contraception, and Condom Use by Young African Women: A Secondary Analysis of Survey Data
Cleland, J. & Ali, M.M. The Lancet (2006), Vol. 368 No. 9549, pp. 1788–93.
In this secondary analysis of public-access data in 18 African countries, the authors examined abstinence, contraceptive use, and condom use between 1993 and 2001 among young single African women. The analysis found little change in the percentage of women reporting to be virgins. However, the percentage of sexually experienced women reporting no sexual intercourse in the previous three months (secondary abstinence) increased significantly in seven of the countries, and the median percentage of women reporting secondary abstinence increased for all countries (43.8 percent to 49.2 percent). Condom use for contraception increased in 13 countries, and the median percentage of women using condoms for pregnancy prevention rose from 5.3 percent to 18.8 percent. In summary, the reported increase in condom use was greater than the increase in abstinence, though an increase in secondary abstinence could have signified a change in sexual partner selection. The authors noted that the period of data analysis pre-dated the wide-scale implementation of abstinence messages. They also underscored the variation in the prevalence of virginity, and noted that diversity of societal attitudes toward abstinence would affect the acceptance of such messages.
Sexual Behavior, HIV and Fertility Trends: A Comparative Analysis of Six Countries: Phase I of the ABC Study
Bessinger, R., Akwara, P., & Halperin, D. USAID-funded MEASURE Evaluation Project (2003).
Data from Demographic and Health Surveys (DHS) were used to compare abstinence, being faithful, and condom use (ABC) behaviors in three countries where HIV prevalence declined during the 1990s: Uganda, Zambia, and Thailand, with three countries where HIV prevalence did not decline in the 1990s: Cameroon, Kenya, and Zimbabwe. In countries with declines in HIV prevalence, there were increases in all ABC behaviors. The same pattern of behavior change was not evident in the three countries that did not experience declines in HIV prevalence; instead, condom use was observed to increase, though little increase in abstinence or partner reduction was reported. In Uganda, the country with the earliest and greatest reduction in HIV prevalence, declines in non-regular and multiple sexual partnerships were greatest between the late 1980s and the mid 1990s, when the rate of new infections (HIV incidence) most likely began to drop. Throughout this decade in Uganda, levels of premarital sex also declined, along with an increase in the average age at sexual debut. Increases in condom use with non-regular partners occurred throughout the 1990s, although levels of condom use were not substantial until the middle of the decade. While the trends in ABC behaviors within these countries are consistent with trends in HIV prevalence, they were not sufficient to fully explain differences in HIV prevalence between countries.
Abstinence and Delayed Sexual Initiation for Youth
Programs that include comprehensive messages can teach skills for practicing abstinence as well as provide information for sexually active youth about condoms and reducing the number of partners.
Abstinence and Delayed Sexual Initiation
Family Health International/YouthNet (2003).
Promoting abstinence is an important strategy that can help delay sexual activity, but complementary messages are needed for youth who are sexually active. This document discusses abstinence programming from a variety of countries, including Jamaica, Uganda, and Zambia.
Abstinence: An Option for Adolescents
Family Health International (2002).
This document explains the importance of abstinence as one of many options for adolescents in Uganda. According to the authors, abstinence offers adolescents, in particular, a number of advantages, such as protection against pregnancy and sexually transmitted infections. However, in practice, abstaining from sex tends to be less effective than many contraceptive methods because complete abstinence requires strong motivation, self-control, and commitment.
Youth Survey Provides Wealth of Data on Behavior to Inform Intervention Strategies
Family Health International/YouthNet (2006).
The Youth Behavior Survey was conducted in 2004 in the Iringa region of Tanzania. Its goal was to gain a fuller understanding of the youth’s HIV knowledge, attitudes, and behaviors to guide prevention programs. One of the main results of the survey was that fear of HIV/AIDS and other sexually transmitted infections was the strongest motivator to remain abstinent.
Condom Use and Abstinence among Unmarried Young People in Zimbabwe: Which Strategy, Who’s Agenda?
Population Council (2003).
This paper compares the views about abstinence and condom use expressed by young people in Zimbabwe in contrast to abstinence-only messages promoted by policymakers and traditional and Christian leaders, and condom promotion messages from private sector and nongovernmental organizations. Evidence from focus-group discussions indicates that adolescents sometimes conceal condom use in deference to adult preferences. Clear and open policies regarding condom use and abstinence should be promoted as complementary alternatives.
No Time to Lose: Getting More from HIV Prevention
Committee on HIV Prevention Strategies in the United States, Institute of Medicine, Washington, DC. National Academy Press (2001). Vol. xi–xii, pp. 118–20.
In this report, the Institute of Medicine, a medical expert body advising the U.S. Federal Government, reviewed abstinence-only activities in the U.S. and concluded that there was no scientific basis to support funding of these programs. The committee recommended using care when considering adaptation of U.S. abstinence-only activities to other settings. The report highlights scientific studies showing that comprehensive sex and HIV education programs, along with condom availability, can be effective in reducing unprotected sexual intercourse and frequency of sex.
Government Support for Abstinence-Only-Until-Marriage Education
Duffy, K., Lynch, D. A., & Santinelli, J. Clinical Pharmacology and Therapeutics (2008), Vol. 84 No. 6, pp. 746–748.
This article discusses the effectiveness of the United States Federal Government’s support of abstinence only-until-marriage (AOUM) programs. AOUM programs are defined as promoting abstinence from sexual activity and limiting discussion of condoms and contraception, except in regard to failure rates. According to the authors, although monetary support for these programs has increased substantially in the past decade, no research has shown that they are effective at preventing teen pregnancies and sexually transmitted diseases. Furthermore, recent analyses reveal that many of these programs contain misleading and medically inaccurate information. Federal support for AOUM programming began in 1982 under the auspices of the Adolescent Family Life Act, greatly expanding after 1996 with the enactment of welfare reform that provided $50 million per year to fund AOUM programs. Although the funding has continued to grow, because of the lack of evidence supporting the protective effects of AOUM programs, health experts, including the Society for Adolescent Medicine, have begun to question the utility of continued funding. Furthermore, the Society for Adolescent Medicine recommends that current funding for abstinence-only programs should be replaced with funding for programs that offer comprehensive, medically accurate sexuality education.
The impact of Uganda’s HIV/AIDS "A,B,C" Prevention Policy On Married Women: Identification of A Need To "Reinvent" A Successful Approach
AIDS- XVII International AIDS Conference (2008). Abstract No. WEPE0813 Al-Bahish.
Uganda is often described as a beacon of hope in HIV/AIDS prevention. Its "ABC" prevention strategy, emphasizing abstinence, being faithful, and condom use, has garnered international attention and acclaim. This policy analysis examines the impact of the ABC strategy on married women by analyzing both quantitative and qualitative data, including governmental statistics, anthropological sources, and human rights literature. The authors explore the interplay among the prevention strategy, gender relations within marriage, and HIV/AIDS risk for married women. They conclude that despite its decreasing prevalence, generally HIV/AIDS is a significant problem for married women in Uganda. Importantly, the disparity in prevalence between married women and other sectors of the population is growing. Aspects of the current prevention strategy, particularly the emphasis on abstinence, provide little to no protection to married women, and may simply reinforce the gender inequities that increase their risk.
Moving Beyond the Alphabet Soup of HIV Prevention
Collins, C., Coates, T. J., & Curran, J. AIDS (2008), Vol. 22 Suppl. 2, pp. S5–S8.
The “ABCs” of prevention (abstinence, being faithful, using a condom) continue to be one of the main focal points of HIV and AIDS prevention policy. “A” (abstinence) can be an important or preferred choice for many individuals, particularly for many young people. Delaying sexual debut is an effective strategy in reducing infection rates among the youngest age group. However, abstinence or being faithful may not be realistic options for many people at different times in their lives. Women in particular may be ignorant of risk they incur as a result of their partner’s behaviors, and they may not be able to insist upon protection. The authors argue that the ABC terminology infantilizes the prevention discussion by placing too much focus on a few activities, instead of promoting comprehensive national prevention programs that have a measurable impact on HIV incidence. Governments, donors, and global agencies should implement prevention programs that are tailored to the specific characteristics of national epidemics; bring quality programs to scale; address environmental factors in vulnerability; and link prevention and treatment services.
Promoting Abstinence: Lessons From Four Countries Over Four Years
Purcell, P., et al. AIDS- XVII International AIDS Conference (2008), Abstract No. CDC0686
Youth for Life (MYFL) is an abstinence and behavior change program from World Relief targeting youth in four countries over five years. Funded by USAID and the President´s Emergency Plan for AIDS Relief (PEPFAR), and started in 2004, this project has reached 1.8 million youth and those who influence them, in Haiti, Kenya, Mozambique, and Rwanda. The program engages youth through interactive training and encourages abstinence before marriage and mutual faithfulness within it as a means to protect against HIV. To understand components of impact and to propose recommendations for improvement, World Relief conducted a mid-term evaluation in all four countries between May and September, 2007. Emergent themes reported by youth beneficiaries and youth influencers included a commitment to abstinence, partner reduction, improved school performance, and identification and reporting of sexual abuse. Youth report that the lessons on self-esteem and making good choices were pivotal to the programs’ impact in their lives; particularly effective was the use of peer role models that moved abstinent couples to marriage.
An Outcome Assessment of an ABC-Based HIV Peer Education Intervention Among Kenyan University Students
Miller, A. N., Mutungu, M., Facchini, E., Barasa, B., Ondieke, W. & Warria, C. Journal of Health Communication (2008), Vol. 13 No. 4, pp. 345–56
This study reports on an outcome assessment of an HIV peer education program initiated in 2004 on the main campus of Kenyatta University in Nairobi, Kenya. The program is being implemented by I Choose Life-Africa (ICL), a local nongovernmental organization. ICL’s early programs focused primarily, though not exclusively, on abstinence messages and other activities such as purity pledges. More recently, abstinence plus activities have been adopted, including advocating for general sexual responsibility, faithfulness, and condom use. After two years of on-campus ABC-based HIV peer education programming, no changes in behavior were evident with respect to either abstinence or number of sexual partners. Small but statistically significant changes were found in condom attitudes and behavior, and a large increase in HIV testing was evident. The authors contend that the effectiveness of peer education is likely to vary depending on contextual and cultural factors related to a given activity. However, the lack of a shift of abstinence and faithfulness indicators in this study raises questions about the ability of peer education to promote behavior change through a comprehensive ABC message. The authors advocate that future studies should compare abstinence-only approaches with full ABC programming.
Impact evaluation of the African Youth Alliance in Ghana, Tanzania, And Uganda: Implications for Future Youth Programming
Posner, J. et al. AIDS- XVII International AIDS Conference (2008). Abstract No. WEPE0320.
In 2005, the JSI Research and Training Institute, Inc. evaluated the impact of The African Youth Alliance (AYA) program, established in 2000 by the Bill & Melinda Gates Foundation and implemented by the United Nations Population Fund, Pathfinder International, and the Program for Appropriate Technology in Health. The evaluation measured whether exposure to AYA’s comprehensive, integrated HIV prevention program resulted in improved adolescent and sexual reproductive health (ASRH), knowledge, attitudes, and sexual behaviors among male and female youth ages 17 to 22 in Ghana, Tanzania, and Uganda. Results demonstrated a significant positive impact on knowledge generation, condom use, contraceptive use, partner reduction, and several self-efficacy and knowledge antecedents. The program had less of an effect on male responsibility, sexual debut, and/or abstinence and partner reduction. Results suggest that a comprehensive, scaled-up, multi-component HIV prevention approach can be effective in improving some key ASRH outcomes.
The impact of Life Skills Education on Adolescent Sexual Risk Behaviors in KwaZulu-Natal, South Africa
Magnani, R., et al. Journal of Adolescent Health (2005). Vol. 36 No. 4, pp. 289–304.
A middle and high school-based Life Skills Program for ages 14 to 24 was conducted in South Africa’s KwaZulu-Natal Province. The curriculum addressed 11 sexual and reproductive health-related life skills topics, ranging from drugs and alcohol to negotiation and assertiveness in relationships. Baseline and two-year follow-up data from 2,222 youth assessed the program’s impact on HIV-related knowledge, attitudes, and behaviors. Knowledge gains were generally minimal and uneven across the topics. The largest changes observed in sexual behaviors were for condom use at first and last sex. Minimal gains were observed for sexual health knowledge and reported self-efficacy to get and use a condom. The proportion of youth who had initiated sexual activity increased by nearly half, though it is important to note that the youth were two years older than at baseline; no change in age at sexual initiation was noted. There were no major effects on age at sexual initiation, secondary abstinence, or number of partners. While school-based life skills programs have the potential of helping youth reduce HIV risk, the long-term benefits of a national education program are unknown.
The United States President’s Emergency Plan for AIDS Relief (PEPFAR) Guidance, Abstinence, Be Faithful, and Correct and Consistent Condom Use (ABC)
This site offers six links to PEPFAR’s ABC approach, including an introduction, defining the ABC approach, and implementing the ABC approach. There are also two appendices: one is on how to determine the appropriate mix of ABC activities and the other is a list of references. The last link is to the original ABC Guidance Number One, which is in PDF format. These documents are designed to provide guidance to the field and missions to implement ABC programs.
Preventing HIV/AIDS in Young People: A Systematic Review of the Evidence from Developing Countries
Ross, D. A., Dick, B., & Ferguson. J.UNAIDS Inter-agency Task Team on Young People. WHO Technical Report Series (2006), No. 938.
This report documents the findings from key studies on youth-based HIV prevention programs organized into categories, depending on whether the evidence is strong enough to recommend the program. The report includes recommendations for policymakers, program development and delivery staff, and researchers. Both chapters five and seven examine the effect of these activities on abstinence as one of the outcomes (Chapter Five: “The effectiveness of sex education and HIV education interventions in schools in developing countries,” and Chapter Seven: “The effectiveness of mass media in changing HIV/AIDS related behavior among young people in developing countries”). These results, by study, are concisely summarized in tables.
The Less They Know, the Better: Abstinence-only HIV/AIDS Programs in Uganda
Cohen, J. & Tate, T. Human Rights Watch (2005), Vol. 17 No. 4A, pp. 1–79.
This article assesses the “ABC” approach that has been heralded as a success in Uganda. Specifically, it cautions that abstinence-until-marriage messages fail to educate young people about accurate HIV and sexually transmitted infection risks and prevention options, and thus violates human rights principles. The authors present a series of recommendations for the Government of Uganda, the United States Government, and all other donors to Uganda AIDS programs. The recommendations focus on supporting effective HIV prevention programming, including encouraging youth to delay sex as part of a comprehensive approach to HIV prevention. The authors discourage use of ideology-based messages, e.g., abstinence-until-marriage, that do not incorporate scientifically effective HIV prevention methods, including condoms, and accurate information about HIV risks.
Abstinence, Fewer Partners, and Condom Use are Complementary Messages
Family Health International (2003).
The first phase of a major six-country study suggests that promotion of sexual abstinence to prevent HIV infection contributed to an approximately one-year delay of sexual initiation among youth in two countries, Uganda and Zambia, where HIV prevalence declined throughout the 1990s.
Preventing HIV with Young People: A Case Study from Zambia
Gordon, G. & Mwale, V. Reproductive Health Matters (2006), Vol. 14 No. 28, pp. 68–79.
This case study examines how Abstinence and Being Faithful programs for youth are being implemented in Zambia. They found that the majority of implementing agencies are supporting abstinence-only activities and have not challenged the overall prevention strategy. Many programs are providing erroneous information about condoms and refuse to distribute them. The authors caution against stigmatizing condoms and those who use them, and encourage all HIV/AIDS programmers to provide a wide range of prevention options to the target populations based on their needs.
What Works: Curriculum Based Programs that Prevent Teen Pregnancy
A summary of effective teen pregnancy programs in the United States that could be tailored to various contexts.
Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy and Sexually Transmitted Diseases
Kirby, D. (2007).
The review summarizes research, describes programs that have reduced teen pregnancy and sexually transmitted diseases, reviews programmatic evidence, and helps implementers select the most appropriate program for their youth.
Tuko Pamoja, "We are Together" Adolescent Reproductive Health and Life Skills Curriculum
PATH & Population Council (2006)
This curriculum builds youths’ knowledge, understanding, and skills about reproductive health, adolescence, sexuality, relationships, sexually transmitted infections/HIV, and other topics. The curriculum is designed for 10- to 14- year-olds and 15- to 19-year-olds and suggests specific modules for each group; session 19 is specifically about abstinence.
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