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[10 September 2007] - The US Senate last week voted to end the most controversial aspect of the PEPFAR treatment and prevention programme: the requirement that one-third of prevention money should be spent on activities that promote abstinence. The President's Emergency Plan for AIDS Relief, also known as PEPFAR, is a five-year, $15 billion American Government initiative to combat the global HIV/AIDS epidemic. Although there were good reasons to believe that delaying sexual activity in young people and limiting partner numbers might have an impact on the spread of HIV, abstinence was seized on by Republicans anxious to curry favour with fundamentalist Christians in the run-up to the 2004 presidential election, in which their votes were so critical. An earmark was inserted into the PEPFAR-enabling legislation, requiring a third of the money to support abstinence. Unsurprisingly the key benficiaries of this earmark were faith-based organisations in the US, who competed to win PEPFAR contracts to run education, care and support programmes in Africa. Yet research in Uganda over the past four years has revealed that focusing on abstinence has been completely misguided. The majority of HIV infections are now taking place within marriages, a big shift from the beginning of the decade. At the same time, there has been little impact on behaviour among young people. Some religious groups in the US have also campaigned against spending PEPFAR money on condom promotion. But a recent study looking at Zimbabwe suggests that condom promotion may bring the greatest benefits in controlling the epidemic, especially if usage can be increased among older men who are having relationships with younger women. In contrast the effect of delaying sex in young women was very modest. Hopefully the fixation on abstinence – the ABC wars – will end. A recent review commissioned by the US government said that PEPFAR funding should not be allocated according to earmarks, but instead should be spent according to the best evidence available at country level. In many southern African countries this will mean a bigger focus on the `B` component of the ABC prevention strategy – being faithful. Concurrent sexual partnerships play a big role in the spread of HIV in Africa, but how to make them safer or stop them is still eluding prevention campaigners, by and large. Re-direction of prevention funds away from programmes organised too rigidly around abstinence could allow us to discover what works on a large scale in tackling the real drivers of the epidemic in Africa – concurrency, poverty and the lack of control over sex experienced by women and girls. Further information