Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Monday, December 10, 2007

Exporting Failure: How The Abstinence-Only Requirement Of PEPFAR Increases HIV Risk In African Nations-Amanda S. Wolfe

The President’s Emergency Plan for AIDS Relief (PEPFAR) was enacted in January 2003 by George W. Bush. The PEPFAR policy is part of the “United States Leadership Against AIDS, Tuberculosis and Malaria Act of 2003” and is the single largest monetary donation by any nation to fund the fight against AIDS (1). The plan proposes a 15 billion dollar donation, over a 5 year time period, to fund AIDS treatment, care, and prevention strategies in 15 nations (2). These nations, referred to as “focus countries”, include Haiti, Vietnam and 13 countries in sub-Saharan Africa. The specific goals of PEPFAR are to support treatment for 2 million HIV infected people, prevent 7 million new infections and support palliative care for 10 million people infected with HIV/AIDS (2). The distribution of PEPFAR funds is determined by Congress and includes a requirement to utilize one third of the PEPFAR budget on abstinence-only-until-marriage programming (3). This paper will focus on PEPFAR’s effects in the nation of Uganda and will contend only with the portion of the policy dealing with prevention programming.

The prevention programming portion of PEPFAR is the only part of the policy that impacts personal health decisions and behaviors. The goal of the prevention programming is to reduce AIDS incidence in these nations by teaching abstinent behavior. Abstinence-only education, as applied in Uganda, operates on the belief that promoting abstinence will have a significant effect on the sexual behaviors of youth (4). Yet evaluations of abstinence-only education programs conducted in the U.S. report no evidence of altered sexual behavior or practices in program participants (5). Supporters of abstinence-only education also believe that that marriage is an effective HIV/AIDS prevention tool, that providing youth with condoms will confuse them about proper abstinence techniques and will encourage them to have sex (4). Again, studies show these beliefs to be unfounded and unsubstantiated (6). Yet this ineffective U.S. prevention methodology is being exported to all nations receiving PEPFAR funds. This policy ignores the social and cultural reality of sexual practices and conduct in Uganda and sub-Saharan nations (7). By requiring abstinence-only education in nations most affected by the HIV pandemic, the PEPFAR program furthers the risk of acquiring AIDS by adopting a power-coercive approach which limits scope of comprehensive prevention education, by mandating educational materials which heighten the risk for HIV transmission when using condoms, and by failing to realistically frame the issue of HIV/AIDS prevention as one that is inaccessible to women.


A brief history of Uganda’s HIV/AIDS prevention efforts is important in order to demonstrate PEPFAR’s use of the power-coercive approach to prevention programming. Prior to PEPFAR’s presence in Uganda, the nation had been heralded as a model country for its efforts to curb the AIDS epidemic (8). Uganda achieved a widely documented “reversal” of the nation’s overall AIDS prevalence of 16% in the mid-1980’s down to 5% by the new millennium (9). The pre-PEPFAR political environment was open to the discussion of sexuality and the reality of disease acquisition. Ugandan President Yoweri Museveni encouraged condom promotion and frank discussion of the disease through media, public education, churches and NGOs (10). Though the term is contentious as to its origin, this has historically been labeled the ABC approach: teaching abstinence, instructing individuals to be faithful to one another, and promoting correct and consistent condom use: Abstain, Be Faithful, Use Condoms (11). This approach brought about a reduction in the stigma associated with the disease and allowed for the discussion of HIV/AIDS to permeate society. With the advent of PEPFAR, however, the climate of political openness in Uganda dramatically changed. President Museveni reversed his position on condom promotion as an effective prevention technique and now aligns the nation’s AIDS prevention strategy by PEPFAR funds received from the United States.

Nations receiving PEPFAR funding are subject to PEPFAR’s programmatic mandates which seek to remove the “C” from the ABC approach (12). Thus, any organization (including schools, hospitals, after-school programs, public health clinics, and NGO’s) that promotes or distributes condoms will not receive PEPFAR funding. By withholding funding for any organizations which do not align with PEPFAR’s mandates, the PEPFAR program employs a power-coercive approach which results in an extreme absence of condom education and supply in Uganda. This places an enormous strain on organizations which offer multiple services such as anti-retroviral treatments along with comprehensive sexual education because they must choose to either stop giving out condoms or lose their funding entirely. Local NGO’s that previously distributed condoms and condom education are now changing the focus of their work in order to be in compliance with their government—they fear losing their funding and being blacklisted for doing what the government and political leaders are opposed to (13). Though PEPFAR is not necessarily national legislation enforced by the nation, it has altered the mindset and political will of the nation. This change has subverted the major component of the public health approach which previously made Uganda a successful model for reversing AIDS prevalence in the nation. A power-coercive approach would ideally enforce behaviors that are beneficial to the public’s health, such as a law requiring seatbelt use. In this instance, though, the power-coercive approach has effectively enforced the elimination of an effective prevention technique for the spread of HIV/AIDS.


PEPFAR’s prevention programming is also manifested the nation’s entire public education system. Prior to 2003, President Museveni created a plan to include comprehensive HIV/AIDS education to all public schools, entitled the “Presidential Initiative on AIDS Strategy for Communication to Youth” (PIASCY). However, since 2003, PIASCY has been fully supported by PEPFAR funds and PIASCY is now the cornerstone of PEPFAR’s abstinence requirement. The original PIASCY educational materials were recalled and revised in 2003 in order to comply with PEPFAR’s abstinence-only requirements. All information pertaining to correct and consistent condom use, including diagrams of a penis with a condom on it, was removed. By eliminating factual condom education from public education, PEPFAR increases HIV/AIDS by disallowing effective education on the disease’s prevention.

The revised materials also include exaggerated failure rates of condoms, claiming that they are less than 65% effective at stopping the HIV pathogen from passing through due to small holes or pores in the latex (13). The CDC has confirmed this as untrue (14) and thus the public education provided to Ugandan youth about HIV prevention is scientifically inaccurate.

This scientific inaccuracy demonstrates a reliance on the Health Belief Model (HBM) as a means to change Ugandan students’ behaviors regarding sex. By heightening the perceived susceptibility to HIV through the use of condoms, it is assumed that this affects the perceived cost of acquiring AIDS. Greater perceived susceptibility, according to the HBM, will alter a student’s intention of having sex. The hope is that the behavior change will result in abstinence. The educational materials fail to include the use of a condom as an acceptable behavior change. Many factors, however, can influence the intention to have sex. Examples of these factors are social/cultural beliefs and practices. In the case of Uganda and other African nations, these social and cultural practices are paramount to the spread of the AIDS but are entirely ignored by the PEPFAR policy. The PEPFAR educational policy instead relies on an antiquated theory of health behavior change and forces useful prevention techniques to be ignored.


The promotion of abstinence until marriage implies the belief that a heterosexual marriage will act as a safeguard against HIV/AIDS. Married women, however, are now more likely than any other demographic to acquire HIV/AIDS (15), thus HIV/AIDS is a gendered epidemic The PEPFAR policy overlooks the reality that the choice to abstain from sex does not lie within the grasp of women in Uganda. Hegemonic and patriarchal national values, which reinforce women’s unequal treatment and status in society, are prevalent in Uganda (15). Traditional practices of forced early marriage, polygamy, lack of access to education and health services, lack of legal or judicial responses to domestic violence or marital rape, and the need for some women to trade sex for material goods are all factors that contribute to women’s general lack of bodily autonomy (16,17). Each of these abuses contributes to the spread of AIDS by disempowering women’s ability to have any rights to protect themselves from the disease. PEPFAR exhibits a complete lack of sensitivity to the reality of women’s rights abuses and AIDS. The effects of PEPFAR’s policy are compounded for women because abstinence-only education is effective only when taught to persons who possess the ability to choose abstinence. Yet, as described above, Ugandan education is dictated by PEPFAR’s power coercive approach—thus women and men cannot access health services or education about methods to protect each other from the spread of HIV/AIDS. Risk is increased when education is unavailable.


The abstinence-only requirement of PEPFAR serves to increase HIV/AIDS risk in all 15 focus country nations by eliminating access to, education and resources to condom education. Denying the use of a proven prevention technique acts to create a new generation of persons requiring AIDS treatment due to their ignorance of prevention techniques beyond abstinence alone. By cutting off the funds of NGO’s providing AIDS services as well as condoms, by overhauling the public education system in order to institute an abstinence education program which has already been proven ineffective in America, and by ignoring the lack of women’s ability to negotiate abstinence, PEPFAR fails to address the reality of AIDS and its prevention. This failure is already being observed. A recent study (18) indicates that the incidence of HIV in Uganda has nearly doubled from 2003 to 2005, from 70,000 to 130,000 new infections respectively. A 2004/2005 National Serostatus Survey reports an increase in the disease’s average national prevalence by .2% in that year alone (19).


1.) U.S. Emergency Plan for AIDS Relief (PEPFAR): Facts and Critical Issues. [online]


2.) PEPFAR 2006 Fiscal Year Operational Plan, April 2006 Update

3.) Global AIDS Alliance Fact Sheet: PEPFAR [online] see

4.) Advocates for Youth, Policy Brief: Improving US Global HIV Prevention for Youth: A Critique of the Office for Global AIDS Coordinator’s ABC Guidance

5.) United States Government Accountability Office Report to Congressional Requesters. “Abstinence Education: Efforts to Assess the Accuracy and Effectiveness of Federally Funded Programs” October 2006

6.) Smoak ND et al. Sexual risk reduction interventions do not inadvertently increase the overall frequency of sexual behavior: a meta-analysis of 174 studies with 116,735 participants. JAIDS 41 (3), 374-384, 2006.

7.) Health GAP Report. “Between The Lines: U.S. Abstinence/Being Faithful-Only Programs Produce Stigma and Death” [online] April 2006. See

8.) Parkhurst J.O. “The Ugandan Success Story” The Lancet 360, 78-80, 2002.

9.) WHO/UNAIDS 2006 Report on Global AIDS Epidemic

10.) Steve Berry and Rob Noble. “Why Is Uganda Interesting?” [online] see

11.) Elaine M. Murphy et al. “Was the ABC Approach Responsible for Uganda’s Decline in HIV?” PLoS Medicine 9, 1443-1447, 2006.

12.) Wairagala Wakabi. “Condoms Still Contentious in Uganda’s Struggle Over AIDS” The Lancet 367, 1387-1388, 2006.

13.) Jonathan Cohen. “The Less They Know, the Better: Abstinence-Only HIV/AIDS Programs in Uganda” Human Rights Watch 17, 2005.

14.) Center for Disease Control and Prevention. “Fact Sheet for Public Health Personnel: Male Latex Condoms and Sexually Transmitted Diseases” Atlanta, GA 2002. See

15.) Engender Health. “Women’s Health in Jeopardy: Women and HIV” [online] see

16.) Lisa Karanja. “Just Die Quietly” Human Rights Watch 15, 1-76, 2003.

17.) Joane Csete. “Policy Paralysis: A Call for Action on HIV/AIDS-Related Human Rights Abuses Against Women and Girls in Africa” Human Rights Watch 2003.

18.) Emma Masumbuko & Joseph Miti, Uganda: 130,000 Got AIDS in 2005, Monitor, May 19, 2006, See also Uganda AIDS Commission website,

19.) “Contentious Condoms”, The Lancet 368, 2006.

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