Abstinence, fewer partners, condom use are complementary messages.

The first phase of a major six-country study suggests that promotion of abstinence from sex to prevent HIV infection contributed to an approximately one-year delay of sexual initiation among youth in two countries--Uganda and Zambia--where HIV prevalence declined throughout the 1990s. (1) In both countries, delayed sexual initiation among youth, abstinence, and condom use with nonregular partners all contributed to declines in HIV prevalence. However, the study concluded, HIV declines were probably due primarily to both adolescents and adults having fewer sexual partners.

In Thailand, a third country where HIV prevalence declined, reductions in commercial sex and other nonmarital sexual relationships and increases in condom use during commercial sex likely contributed to the decline. This type of multifaceted behavior change did not occur to the same extent in the other three countries in the study--Cameroon, Kenya, and Zimbabwe--where HIV prevalence did not decline.

Thus, the "ABC strategy" (abstinence, be faithful to one partner or reduce number of partners, or--if "A" or "B" cannot be achieved--use condoms consistently and correctly) continues to be an appropriate general recommendation. And messages to delay sexual initiation or to begin practicing abstinence even after having been sexually active need to be an integral part of programs to prevent HIV, other sexually transmitted infections (STIs), and pregnancy among unmarried youth.

Delaying sexual initiation

Throughout the world, the age of puberty is falling while the age of marriage is generally rising. These factors result in a longer period during which unmarried youth can be sexually active, often in a series of monogamous relationships. In demographic and health surveys among 15- to 19-year-olds, more than 25 percent of boys in Brazil, Gabon, Haiti, Hungary, Kenya, Latvia, Malawi, Mozambique, and Nicaragua reported having had sexual intercourse before they were 15 years old. Generally, more than 15 percent of surveyed girls reported having had intercourse before age 15. (2)

For behavioral as well as physiological reasons, early sexual debut increases adolescents' risk for infection with HIV and other STIs. Youth who begin sexual activity early are more likely to have high-risk or multiple partners and are less likely to use condoms. (3)

Many factors affect the timing of sexual debut. A World Health Organization review of studies in 53 countries found common protective factors and risk factors throughout the world. Having positive relationships with parents and teachers, holding spiritual beliefs, and attending school were associated with a decreased likelihood of early sexual debut. In contrast, engaging in other hazardous behaviors and having sexually active friends were associated with an increased likelihood of early sexual debut. (4)

Delaying first sex or abstaining from sexual intercourse after having been sexually active may be difficult. Youth may not practice abstinence perfectly, just as they might not use condoms consistently and correctly. Some may consider themselves to be practicing abstinence if they abstain from vaginal intercourse, even if they engage in other kinds of sexual intimacy. A young person may have sexual intercourse in a "weak" moment, which emphasizes the need to help youth develop abstinence skills. Other youth may be coerced into sexual intercourse. In a study conducted in KwaZulu Natal, South Africa, a province greatly affected by the HIV/AIDS epidemic, 24 percent of some 800 girls ages 15 to 24 years reported having been "persuaded" or "tricked" into their first sexual experience. (5)

However, delaying sexual debut or abstaining from sexual intercourse after having been sexually active can be empowering. "Youth may lack power in many aspects of their lives," said Dr. Nancy Williamson, director of YouthNet and an FHI vice president. "But most youth do have the ability to abstain from or delay sex, once they understand the benefits of doing so."

References

(1) Bessinger R, Akwara P, Halperin D. Sexual Behavior, HIV, and Fertility Trends. A Comparative Analysis of Six Countries. Phase I of the ABC Study. Washington, DC: U.S. Agency for International Development, Measure Evaluation, 2003.

(2) United Nations Children's Fund (UNICEF). Young People and HIV/AIDS: Opportunity in Crisis. New York, NY: UNICEF, 2002.

(3) World Health Organization. The context of young people's sexual relations. Progr Reprod Health Res 2000;53:2-3.

(4) World Health Organization. Broadening the Horizon: Balancing Protection and Risk for Adolescents. Geneva, Switzerland: World Health Organization, 2002. Available: http:// www.who.int/child-adolescent-health/New_ Publications/ADH/WHO_FCH_CAH_01_20.pdf.

(5) Manzini N. Sexual initiation and childbearing among adolescent girls in KwaZulu Natal, South Africa. Reprod Health Matters 2001; 9(17):4452.

Claudia Daileader Ruland, YouthNet Information Dissemination