Background: The United States President’s Emergency Plan for AIDS Relief (PEPFAR) supports more abstinence and faithfulness programs in sub-Saharan Africa than any other funder. We assess the relationship between PEPFAR’s support for these programs and changes in high-risk sexual behavior. Evaluating the outcomes of foreign aid for HIV is important for optimizing HIV treatment and prevention portfolios.
Methods: Using individual-level nationally-representative survey data from the Demographic and Health Surveys for 22 sub-Saharan African countries, we employed a difference-in-differences analysis to assess the relationship of PEPFAR abstinence and faithfulness funding to changes in three outcomes indicative of high-risk sexual behaviors: the number of sexual partners, age of first sexual intercourse, and teenage pregnancies. We compare trends in these outcomes among persons living in PEPFAR funded and non-PEPFAR countries from 1998 to 2013.
Results: We analyzed 252,251 men and 591,714 women using 54 surveys in 14 PEPFAR funded and 8 non-PEPFAR funded countries. In comparison with non-PEPFAR countries, survey respondents living in PEPFAR countries exhibited no relative change in the number of sexual partners among men (0.02 more partners; 95% CI (-0.04, 0.08); p=0.48), number of sexual partners among women (0.02 fewer partners; 95% CI (-0.05, 0.01); p=0.15), age of first sex among men (0.10 years earlier; 95% CI (-0.91, 0.70); p=0.79), age of first sex among women (0.19 years earlier; 95% CI (-0.76, 0.37); p=0.49), or in rates of teenage pregnancy (2% relative decline in prevalence; 95% CI (-7, 2%); p=0.34).
Conclusions: We find no evidence to suggest that PEPFAR funding of abstinence and faithfulness programs results in reduced high-risk sexual behavior. These results suggest the importance of examining alternative funding priorities for PEPFAR to improve HIV prevention in sub-Saharan Africa.