Abstinence in HIV prevention: science and sophistry - Authors' reply.

www.thelancet.com/lancetgh Vol 5 January 2017 e31 Abstinence in HIV prevention: science and sophistry Authors’ reply In response to our Comment, Chika Uzoigwe and Luis Sanchez Franco accuse us of sophistry in reporting the best available evidence, which suggests that the promotion of abstinence and fidelity does not prevent HIV, sexually transmitted infections (STIs), or unwanted pregnancies—evidence supported by the fi ndings of a Lancet Commission and adopted as an appropriate public health response by the UN General Assembly. Uzoigwe and Sanchez Franco fail to grasp a basic distinction in epidemiology between efficacy and effectiveness. Efficacy refers to the effect of an intervention under controlled or ideal conditions, and effectiveness refers to its effect in real-world situations. By way of illustration: driving leads to road traffic injuries. Abstaining from driving would eliminate such injuries—an effi cacious intervention. In the real world, where people rely on motorised transport, the use of driver education programmes, seat belts, and other harm-reducing measures is seen as a more realistic approach than abstinence, and offers some proven eff ectiveness against injuries (although not enough). Uzoigwe and Sanchez Franco present some spurious arguments. They cite tobacco and advocate for abstinence—omitting to mention the absence of any known health benefi ts from smoking. A better analogy would be nutrition. Several undesirable eff ects can happen if people eat the wrong foods or too much of the right foods. It is our duty as health professionals not to stop them from eating but to guide them to healthy eating choices. We posit that there are many health benefits from pleasurable and safe sexual experiences, free of coercion, discrimination, and violence. But in the real world there are risks from unsafe sex, including unintended pregnancies, STIs, and HIV. Hence, we support programmes based on evidence to reduce those risks—rather than specious notions of abstinence (for how long?) or reducing the number of sexual partnerships (what would a safe number be exactly?). Comprehensive sexuality education, challenging harmful social norms, the empowerment of young people, and access to condoms and other contraceptives are eff ective, although not perfect, options. We should ensure that all people, young and old, can enjoy the benefits of positive approaches to sexual health, including sexual relationships—safely and consensually. There exists a wider moralitydriven, political project that seeks to limit sexual rights—including prohibiting comprehensive sexuality education, abortion, and same-sex sexual relations. Once again, we see that ensuring sexual and reproductive health and rights for all requires more than evidence, it requires managing the inherent politics therein.