AIDS prevention: Abstinence vs. risk reduction

Esther Duflo, 20 April 2009

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On his first visit to Africa, Pope Benedict XVI reiterated that the distribution of condoms by health authorities won’t resolve the AIDS epidemic in Africa, adding that “on the contrary, it increases the problem.”

The Pope outlined “the only solution,” a “two-fold” approach involving “the humanisation of sexuality, spiritual renewal which brings with it new ways of behaving” as well as “true friendship, especially for those who are suffering” (Ward 2009). In short, what the Catholic Church and many other churches have been advocating to fight AIDS – abstinence and fidelity.

As the editors of the Lancet have forcefully said, the Pope’s assertion that condoms increase the problem was outrageous; an insistence, in fact, that the world is flat when all evidence shows the contrary. All evidence finds that condoms save lives.

If only the Pope was so misguided, one should certainly feel very sorry for the Catholics around the world. But leaving the outrage aside, there remains the tension between risk avoidance and risk reduction, which is present as a choice in every prevention program and is thus a much broader issue.

Risk avoidance centres on foolproof solutions. For the youth, abstinence followed by mutual fidelity is a 100% effective preventive practice. Risk reduction, on the other hand, focuses on adopting less risky, and easier to adhere to, forms of the behaviour. Using condoms is highly effective, and it is easier than abstinence. What, then, should be the message of a prevention program targeted at the youth?

The tension is pointed for youth. Children aged 5 to 14 years have been called a “Window of Hope”, because they have low HIV infection rates and their sexual behaviour is yet malleable. If they learn and internalise safe sexual practices, then by the time they cease to abstain, they will practice safe sex. The majority of these children now attend some primary school; thus school is becoming the locus for HIV prevention education targeted at children. But what is the message?

AIDS prevention programs for youth in Africa are a delicate balance resulting from negotiations among civic groups, various churches, international organisations, and governments. The result has been an emphasis on risk avoidance, in order to pacify the churches that see the fight against HIV as an opportunity to bring about a more moral society. In East Africa, for example, the message is “ABCD” – Abstain, Be faithful, use a Condom...or you Die.

It’s a message that builds up and reflects the tension between the risk avoidance and reduction but gives priority rather unambiguously to avoidance. But at least, unlike the Pope’s statement, this leaves some space for condoms if abstinence and fidelity have failed.

New research findings

For public health policy, the tension should only be broken by research – by what is proven to work. A large-scale randomised evaluation conducted by J-PAL in rural Kenya provides insight into the relative effectiveness of risk avoidance (the ABCD curriculum) and risk-minimisation strategies (Duflo, Dupas, Kremer, Sinei, 2006; see also J-PAL 2007).
The results suggest that training teachers to deliver an ABCD curriculum increases the time spent on AIDS education in schools but does not change reported sexual behaviour or knowledge about AIDS. In addition, one, three, and five years after intervention, pregnancy rates among adolescents are the same (about 5%, 14% and 30% respectively) in schools where teachers were trained and where they were not.

The content of the message may explain why teacher training had no impact on childbearing rates. It covers basic medical facts about AIDS, HIV transmission, prevention (excluding condoms), and care for people living with AIDS. It stresses abstinence until marriage as the most effective way to prevent HIV. Risk reduction is not covered. This content may be leaving teachers imparting a lot of information but little practical wisdom, such as information that is actionable for reducing risk once students make the transition from abstinence. One possibility for risk reduction is to provide information that allows people to choose safer partners. A striking feature of the distribution of HIV is that young women aged 15 to 19 are five times more likely to be infected than young man in the same cohort. And their infection rates match those of men in older cohorts, which suggest that intergenerational sexual relationships pose a great HIV risk for young women.

Thus, the second program (Dupas, 2009) simply provided students information on the distribution of HIV infection by age and gender (relative risk). This can readily be used in selecting less risky partners. The program had a large impact on the incidence of unsafe sex with the riskiest partners – older men or “sugar daddies.” Teenage girls who benefited from this program reported having sex less frequently with older men and more often with boys their own age (with whom they use condoms more easily). After a year, the pregnancy rates were 5.5% in schools that had not received the program and 3.7% in schools that had received it. This reduction is mainly due to a 67% reduction in pregnancies with an older partner.

But understandably the churches cannot go against their central teachings; they cannot go beyond “AB.” How can they help?

First, they should show grace by investing their energies in advocating solutions that agree with their principles and refrain from undermining public health solutions that, while not in line with their beliefs, are effective at savings lives. This is the responsible thing, given that there are many in Africa and elsewhere who will live and die by their guidance.

Second, they can invest in increasing possibilities for girls, by reducing cost to help girls stay in school longer. A program to reduce the cost of schooling, by providing school uniforms, with the aim of helping youths stay in school longer, reduced marriage and childbearing rates by 10%.

The program was based on the hypothesis that out-of-school teenage girls face fewer incentives to avoid pregnancy than girls in school. For one, they no longer face the high opportunity cost of discontinuing their education to start a family. (Even though pregnant girls have the legal right to stay in school, they often face strong social pressure to quit.) So reducing the cost of education raises the opportunity cost of pregnancy – and of unprotected sex. The observed decrease in childbearing rates suggests a decrease in the incidence of unprotected sex, and, likely, fewer new HIV infections (Duflo et al. 2006).

This does not violate any religious tenets and works by the same logic as that used to argue against condoms, except the opportunity cost of sex is not the ultimate price, the very life of the person involved. Further, girls would gain the benefits of education.

Altogether, the findings show that, while general messages fail, a clear message that suggests practical ways of limiting risk can save lives. There are 22 million people living with HIV in Africa – it is high time that leaders of different churches showed the grace needed to have a realistic discussion of AIDS and to find a way to balance their obligations to provide both spiritual and practical wisdom to their communities.

References

Abdul Latif Jameel Poverty Action Lab (2007) Cheap and Effective ways to Change adolescent sexual behaviour. Policy Briefcase number 3

Pascaline Dupas (2009) “Do teenagers respond to HIV risk information” NBER Working Paper 14707

Esther Duflo, Pascaline Dupas, Michael Kremer, and Samuel Sinei (2006), “Education and HIV/AIDS Prevention: Evidence from a Randomized Evaluation in Western Kenya,” Working paper, MIT (2006)

Olivia Ward (2009) , “Pope’s condom remarks ‘real tragedy.” Toronto Star, March 18.

Topics: Development, Health economics
Tags: abstinence, Africa, AIDS, condoms, randomised experiment, religion

Professor of Economics at MIT and a CEPR Programme Director