Abstinence

Until better prevention methods are available, the only way to ensure freedom from the risk of HIV infection, for many people, is to forgo sex. In some populations in low- and middle-income countries, the median number of sexual partners newly-diagnosed women have had is one, and getting married is an HIV risk factor. Condoms are unavailable to many people and in many locations. In any case, condoms cannot be used by couples trying to conceive and their use within marriage and long-term primary relationships is the exception rather than the rule (see Condoms and lubricants for these data).

In these circumstances, and for vulnerable young people in general, the most effective HIV prevention intervention may be a programme that encourages them to forgo sex altogether, to forgo penetrative sex, to delay it until within a monogamous relationship or marriage, or to encourage both members of a couple to practise strict monogamy (once tested for HIV, if a test is available, and found to be negative).

If delaying sex and reducing the number of sexual partners people were simply public health measures and not the only choices available to people reducing their HIV risk, encouraging abstinence and fidelity would not be a controversial idea.

However, it is extremely difficult to keep questions of sexual morality, sexual stigma and discrimination against women and sexual minorities out of the debate. The benefits of abstinence and fidelity have become entangled with the virtues of marriage, and it has been hard to separate personal choices from dominant cultural norms. The promotion of condoms has been portrayed as the promotion of promiscuity. Conversely, and in reaction to the perceived morality of the majority, ‘great sex’ has sometimes been portrayed as a right and a good thing in itself; suggesting or influencing people to delay or restrict it has been seen as oppressive.

Social desirability may also lead to a misrepresentation of the contribution of abstinence and fidelity to HIV reduction, if survey respondents feel uncomfortable telling the truth about having sex, especially when it is extramarital or unprotected.

And changes in HIV prevalence that may in fact be due to a high death rate in people with HIV, a higher proportion on treatment, or simply the natural dynamics of an epidemic, may be wrongly attributed to changes in sexual behaviour.