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U.S. Push for Abstinence in Africa is Seen as Failure Against H.I.V.

DONALD G. McNEIL Jr.
hiv and africa

The $1.3 billion that the United States government has spent since 2005 encouraging Africans to avoid AIDS by practicing abstinence and fidelity did not measurably change sexual behavior and was largely wasted, according to a study presented on the last day of an AIDS conference here.

The study, done by a second-year student at Stanford Medical School for a professor with an expertise in cost-benefit analyses, caused a major stir in the room where it was presented.

The researcher, Nathan Lo, analyzed records showing the age of people having sex for the first time, teenage pregnancy and number of sexual partners in international health surveys that have been paid for by the State Department since the 1970s.

His work was overseen by Dr. Eran Bendavid, an assistant professor of medicine at Stanford, who has done previous analyses of American global anti-AIDS programs for the Institute of Medicine, a branch of the National Academy of Sciences.

Global health specialists came to the microphone to congratulate Mr. Lo, who had received a Young Investigators’ award from the International AIDS Society that paid his way to the conference. Advocates who had long opposed the American policy that sought to prevent AIDS by promoting abstinence and faithfulness applauded.

“That was fantastic,” said Dr. Gilles van Cutsem, medical coordinator for Doctors Without Borders in South Africa.

Staff members from the government program that Mr. Lo had accused of wasting money — Pepfar, the President’s Emergency Plan for AIDS Relief — came up afterward to quietly congratulate him. When they realized a reporter was present, they nervously asked that they not be named.

President George W. Bush’s global AIDS plan was enacted in 2003 and marshaled billions of dollars to treat Africans who had AIDS with lifesaving drugs. Conservative Republican leaders in the House of Representatives successfully included a provision that one-third of AIDS prevention money go to programs to encourage abstinence and fidelity. That campaign — known as ABC, for abstain, be faithful and use condoms — was part of the bargain made when Christian conservatives joined with liberals to pass the law.

After Mr. Lo gave his presentation, the moderator asked if anyone from Pepfar in the room would respond. A woman identifying herself as a director of Pepfar’s efforts in an unidentified country said the program — which is led by Dr. Deborah Birx — had just cut the $47 million it still spends on abstinence and fidelity to $21 million. Beyond that, she said, she would have to wait until people at headquarters could read the study.

A spokeswoman for Dr. Birx declined to comment in an email.

Dr. Mark Dybul, who directed Pepfar during most of the Bush administration and now runs the Global Fund to Fight AIDS, Tuberculosis and Malaria, said by email that he did not wish to comment. He noted that previous studies by Dr. Bendavid had shown that Pepfar prevented infections and saved lives.

Michael Gerson, now a columnist for The Washington Post who was a Pepfar advocate and a close adviser to President Bush, also said he would have no comment on the study until the experts he trusted could read it.

Mr. Lo said he spent a year analyzing dozens of health surveys that the United States paid for in countries around the world.

Originally called the World Fertility Surveys, they were begun in the 1970s. They were later subsumed into the large Demographic and Health Surveys, now paid for by the United States Agency for International Development, that document health behaviors in dozens of countries. Spending on abstinence and fidelity peaked in 2005 and began to drop after the Obama administration took office in 2009.

Mr. Lo compared data from 1998 to the present in 22 African countries, 14 of which received Pepfar money and eight that did not. He looked at answers to three questions that are part of the extensive questionnaire given to people interviewed: What was your age when you had sex for the first time? At what age did you have your first child? How many people have you had sex with in the last year?

When answers about age at loss of virginity did not appear to be truthful, he said, he used a conservative form of adjustment, calculating backward from the birth of the first child.

Although the numbers changed over time, the differences between the Pepfar and non-Pepfar countries did not change after 2005. That indicated “no detectable effect” from the expenditure, he said.

The differences were so small that, for example, men in the Pepfar countries appeared to have 0.02 more sexual partners after the abstinence and fidelity funding began than they had before.

In the past, Dr. Bendavid said, he approached Pepfar’s chief medical officer more than once suggesting that the Demographic and Health Surveys be used to analyze the effectiveness of the abstinence and fidelity efforts.

“He said it was outside their purview,” Dr. Bendavid said.

PUBLISHED:FEB. 26, 2015

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