Abstinence in Africa

Abstinence-only programmes have been taken up enthusiastically by some African religious and political leaders. However, when programmes have been exported to Africa, the rigid “don’t have sex” message has tended to get diluted into a more realistic and probably more effective “delay sex or reduce your number of partners” message.

In 2005, the lobbying group Human Rights Watch¹ criticised an apparent policy shift towards abstinence-only programmes in Uganda, 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 realised 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 its 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 the chart below – and this may have contributed to declining HIV incidence (see B is for being faithful). But the sharpest decline happened in the mid-1990s, long before abstinence-only as an approach had been adopted in the 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’.

In 2006, HIV activist and prevention advocates in Uganda expressed concern that the new emphasis on abstinence-only programmes and restrictions in condom supply were reversing two decades of successful HIV prevention work, after a survey found that HIV prevalence was starting to increase again.² The national serostatus survey for 2004-05 showed that average national prevalence was 6.4%, slightly up from 6.2% just over a year previously. Infection was shifting from the young people to adults aged between 30 and 40 years. Prevalence rates have traditionally been higher among younger people, so the new trend baffled health workers. There are at least 1.4 million Ugandans living with HIV.

"Infection is high among adults now and we must ask ourselves why," said Vice President Gilbert Bukenya, a medical professor. He said the issue of condom use needed to be reviewed as the country sought explanations for the rising prevalence rates. "The issue of condoms was politicised. Much as the religious sector is against it, I feel there are people who can't be left out. The issue must be re-addressed."

Two incidents had led to condoms being de-emphasised as the main weapon in the fight against HIV/AIDS. The first was Janet Museveni’s campaign. Secondly, a recall of some brands of condoms in 2004-05 due to concerns about their quality led to a national shortage.

A 2005 study by researchers at Makerere University and the AIDS Information Centre showed that when condoms were used by most Ugandans aged 19 to 25, they were primarily considered contraceptive tools rather than protection against infections. These findings have added weight to calls from local and international health groups for President Museveni and his government to commit to promoting the ABC strategy properly, rather than trying to downplay the utility of condoms in HIV prevention.

In 2006, a review of the HIV prevalence and sexual behaviour data from Uganda³ concluded that the falls in HIV prevalence seen had been caused by a complex mix in reduction in casual sex and extramarital sex, increased condom use, and changes in social attitudes towards sex and sexual equality, especially amongst men, amongst whom behaviour had changed more than in women. Behaviour changes also included abstinence in young people: median age at first sex rose by 1.2 years for girls and 1.7 years for boys between 1989 and 2000, the percentage of 15- to 19-year-old women ever having sex dropped from 74% to 51% and among men of the same age, from 68 to 42%.

However, increased condom use was important, too. Among unmarried men aged 15 to 24, reported condom use at last sex increased from 39% in 1995 to 57% in 2000. “De-emphasising the importance of condom use has the serious potential to hurt local prevention efforts,” comment the authors.

A more imaginative way of using abstinence from sex as a component of HIV prevention has been suggested by Alan Whiteside of KwaZulu Natal University in South Africa and Justin Parkhurst of the London School of Hygiene and Tropical Medicine (LSHTM). They suggest that high-prevalence countries should test whether promoting a national month of sexual abstinence could slow the spread of HIV, by interrupting the chain of transmission during the primary, highly infectious stage of HIV infection.⁴

HIV levels are highest in the month to six weeks after infection, before immune responses begin to control the virus. Individuals in this phase of infection may account for anywhere from 10 to 45% of new HIV infections. Stopping large numbers of recently infected people from passing on the virus for a month could act as a ‘fire break’, in the same way that trees are chopped down in a forest fire to break the progress of the fire.

They speculate that, in addition to universal male circumcision, one reason why Muslim nations have much lower HIV prevalence is because during the fasting month of Ramadan observant Muslims are expected to abstain from sex during daylight hours. The authors highlight the World Health Organization’s ‘tobacco-free’ days and suggest that campaigns – even temporary – can reduce risk behaviour across a population.

Mathematical modelling would be needed to show that the idea could work; then national campaigns should be conducted to test the hypothesis.