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Science
May 14, 2011
“We haven’t seen any evidence that condoms or higher condom use has reduced HIV rates in Africa,” says Dr. Edward Green, the director of Harvard’s AIDS Prevention Research Project.

While on his way to visit Africa in March, Pope Benedict noted that condom promotion had not halted the spread of HIV on that continent and, in fact, may have made the situation worse. Predictably, politicians and the media erupted in fury, denouncing the Pope for opposing the supposedly life-saving expedient of using condoms. The parliament of Belgium even passed a resolution calling the Pope’s statement “unacceptable.” The story was cast in terms of oppressive religion versus liberating science. Yet the science is all on the Pope’s side.

According to Zenit (March 18, 2009), the Pope told journalists while travelling to Africa, “I would say that this problem of AIDS can’t be overcome only with publicity slogans. If there is not the soul, if the Africans are not helped, the scourge can’t be resolved with the distribution of condoms: on the contrary, there is a risk of increasing the problem. The solution can only be found in a double commitment: first, a humanization of sexuality, that is, a spiritual and human renewal that brings with it a new way of behaving with one another; and second, a true friendship, also and above all for those who suffer, the willingness—even with sacrifice and self-denial—to be with the suffering.”

The sad fact is that southern Africa continues to face a massive pandemic of HIV/AIDS despite decades of equally massive condom promotion. The only country that has achieved a large reduction of its HIV infection rate is Uganda, which pushed its rate down from 18 percent to 5 percent some years ago. And Uganda did it through emphasizing abstinence and faithful monogamy under the direction of President Yoweri Museveni and his wife.

So why don’t condoms work? Part of the explanation is people’s refusal to use them consistently, and inconsistent use is close to useless. “After 25 years of promoting condoms aggressively for disease prevention, it’s been impossible to get people to use condoms, no matter what we do or what we try,” Dr. Edward Green, director of Harvard’s AIDS Prevention Research Project, told CWR.

In contrast, campaigns to get people to reduce their numbers of sexual partners and be faithful have succeeded, in a curious inversion of the conventional wisdom promoted by the culture of death; people have responded to messages about abstinence and faithfulness and modified their behavior, but have not responded as strongly to messages about the necessity of consistent condom use.

The Catholic archbishop of Abuja, Nigeria, John Onaiyekan, wrote a letter defending the Pope based on his own experience of fighting AIDS in his country.

“As an archbishop dealing on a daily basis with people infected and affected by HIV/AIDS, I know that the Pope is speaking the truth,” he said. “I suspect that those who were so vociferous in condemning the Pope have never touched an HIV-infected person, let alone rendered any care and attention. It is so much easier to distribute gadgets, especially at other people’s expense. What reduces infections is less casual sex, not more condoms. That is the truth. Those who accuse the Pope of being ‘unrealistic,’ that young people will have sex anyway, have no respect for the young people. When they are given true orientation, they freely respond with far greater sexual responsibility than the armchair social experts can ever imagine.”

“There are two types of epidemics,” explained Green, who also wrote an op-ed for The Washington Post defending the Pope’s comments. “One is among general populations and the other among high-risk groups.” In highly-controlled settings among people with high risks of contracting HIV, such as prostitutes in brothels, where proper condom use can be enforced every single time, there is evidence that condoms retard HIV transmission, said Green, a self-described liberal who does not believe that condom use is immoral. But among general populations, it’s a different story. “We haven’t seen any evidence that condoms or higher condom use has reduced HIV rates in Africa,” he said.

MORE REALISTIC THAN HIS CRITICS

In fact, as the Pope mentioned, condom promotion can lead to higher HIV rates in the real world because of the psychology of real people, most of whom do not use condoms consistently. “People who use condoms intermittently have an increased sense of safety,” said Green, and thus tend to engage in “riskier behavior,” negating any safety advantage provided by the condom use.

This year, and for the first time, according to Green, even the United Nations has begun releasing reports emphasizing the importance of more chaste sexual behavior rather than condom use. Promiscuity is rampant in sub-Saharan Africa, with large numbers of women as well as men regularly having more than one ongoing sexual relationship at any given time. This greatly enhances the spread of HIV.

One report from UNAIDS, the collaborative agency linking many different UN branches in the fight over AIDS, focuses on reducing the multiple and concurrent partnership (MCP) phenomenon in southern Africa.

“Epidemiological modeling suggests that even a relatively small reduction in MCP would break up extensive sexual networks and could significantly slow the spread of HIV in the sexually active population. And the real-world epidemiological evidence to date suggests that reductions in multiple sexual partnerships have probably already had a considerable impact on HIV transmission in several parts of Africa,” says the report. “In Uganda, HIV prevalence declined dramatically following the intensive ‘Zero Grazing’ campaign of the late 1980s; large WHO surveys conducted between 1989 and 1995 found an approximately 60 percent reduction in the number of men and women reporting multiple and casual partners. And in Kenya, partner reduction similarly is the main behavioral change associated with the more recent HIV decline there.”

There is no shortage of other countries in which trends toward traditional sexual morality may make a difference. “Similar reductions in multiple partnerships have been reported in [Demographical and Health Surveys] and other surveys in Zimbabwe where HIV has also fallen, in addition to Ethiopia, Côte d’Ivoire, and urban Malawi. In Swaziland, the number of people reporting two or more partners during the past month was halved after an aggressive 2006 campaign focusing on the danger of having a ‘secret lover,’” the report says.

So not only do public campaigns against promiscuity work—Green believes they work much better at promoting monogamy than they do at promoting complete abstinence—but they have also been linked strongly to reductions in HIV transmission rates. Condoms haven’t.

In his book Rethinking AIDS Prevention, Green notes, “Condom effectiveness is not just an issue in Africa. A prospective study of condom use in Baltimore found no differences in STI [sexually transmitted infection] rates among those who reported using condoms 100 percent of the time versus 0 percent of the time.” Maybe consistent condom use isn’t all that effective in the real world after all, said Green, or maybe those who claimed to be using condoms 100 percent of the time were not.

Unfortunately, there is not a lot of data available directly measuring the effect of consistent condom use in the real world. “We might find out that consistent condom use does not work,” said Green, who is analyzing data on that subject now. He said that condom promoters may have a lot of data, but have not released any showing proof that their product works. “If you were invested in condoms, and you have the data to prove it [they work or they don’t], and you didn’t release it, what would that suggest?” Green asked.

BEHAVIOR CHANGE AS THE KEY

Green believes that among experts who focus on data from Africa, the realization that behavior change rather than condom use is the key to AIDS prevention is beginning to sink in. “AIDS is the only disease with no primary prevention strategy, no emphasis on changing behavior,” he said. “Instead, the emphasis is on secondary prevention strategies…. If you told gay men that they could drop their risk of HIV to that of gay women, a big reduction, just by not having anal intercourse, just by not engaging in that one behavior, it could make a big difference. But that is not emphasized.”

Steve Mosher, president of the Population Research Institute and an opponent of condom distribution as immoral and counterproductive, said that just because medical researchers may be beginning to come around on the question of condoms doesn’t mean that anything will change on the ground in Africa. “We’ve seen that experts in the field can be ignored by most of the practitioners in the field,” he said. For example, most demographers now recognize the dangers of low birthrates in most of the world, but population activists continue to promote population control. PRI has commissioned studies that have found that African women most desire maternal care, antibiotics, and other basic health care, but that international aid agencies focus on contraception.

If anything, the African experience shows the wisdom of Christian teachings. “Having concurrent partners greatly increases HIV transmission compared to sequential or serial partnerships because new infections can spread much more rapidly through the sexual network when its members are simultaneously connected, and also because of the greatly increased viral load in acute (early stage) HIV infection that facilitates transmission,” says the UNAIDS report, which promotes as one of its ideals, “Aspire to mutual monogamy or, if in a polygamous relationship, ensure this is a closed circle of relationships; and believe that men can control their sexual impulses.”

The report notes that most studies have failed to adequately investigate the MCP phenomenon. “Current population surveys often measure multiple partnerships as two or more sexual partners over the last 12 months, which does not differentiate concurrent or other multiple partnerships. Indicators and research methods that do identify concurrency are needed,” it says.

Interestingly, two biblical proscriptions are the only strategies proven to reduce HIV transmission. Green said that “male circumcision and fidelity” are the only things shown to work.

A second UNAIDS report also promoting a reduction in MCP outlines how dire the situation in Africa remains. “More than 25 years into the global HIV epidemic, southern Africa remains the region carrying the highest burden of HIV and AIDS globally,” it says. “Eight countries in the region have reported an adult prevalence rate in excess of 15 percent. In 2007, 1.5 million new infections occurred in the region accounting for almost one-third of all new HIV infections and AIDS-related deaths around the world.” The report even allows a place for religious groups’ message. “Other considerations included: how best to involve faith organizations, and whether moralistic messaging from local faith groups could be useful provided it does not detract from condom messaging,” it concedes.

“DEATH BY CONDOM”

Dr. George Mulcaire-Jones, president of Maternal Life International, has worked in Cameroon and wrote a program called “The Faithful House,” used in Africa to promote Catholic teachings. “[A]s the evidence has emerged, starting with Uganda, we now know the Church and the Pope were absolutely right,” he said in an interview. “Guess who was really complicit in genocide: the condom makers, promoters, and the public health establishment that was vested in a condom ideology.”

Like Green, Mulcaire-Jones believes that condom use doesn’t work in the real world due to human psychology. “Part of the Pope’s comments has to do with a phenomenon called ‘risk compensation,’” he said. “It is more technical public health term which reflects a reality about human behavior in which, once a ‘primary risk’ is lessened by a technological intervention and is perceived as less dangerous, then the behavior may actually increase. One well-documented example is what has occurred in the homosexual community with the widespread use and availability of antiretroviral medications. Because the perceived risk of HIV transmission is lessened because of reduced viral loads, the fundamental behavior—promiscuity and increased number of sexual partners— has increased.”

Mulcaire-Jones believes that condom promoters are trapped in their own ways of thinking. “Condoms and the ideology behind them have operated on a superficial level of consciousness, proposing a mechanical solution to a value-based moral and behavioral problem. We should not be surprised they have failed; they never penetrated the level of consciousness necessary for changing behavior and social norms,” he said. “The beauty and wisdom of the Church is it penetrates the deepest levels of consciousness and therefore offers a solution which is authentic. As it does, it reveals the sophistry of other supposed solutions. Deceit leads to death—in this very sad epoch of human history, death by condom.”

Catholic activists fear that the new Obama administration, so far intent on promoting pro-death policies at every turn, will also alter President Bush’s huge anti-AIDS effort in Africa. Dr. Eric Goosby, Obama’s choice to replace Mark Dybul as the United States’ global AIDS czar, will be under pressure to defund Catholic and other anti-AIDS programs that do not promote condoms.

Catholic League President Bill Donohue said in an April 28, 2009 press release, “Dr. Mark R. Dybul was in charge of this office under President Bush. An openly gay man, he worked to insure conscience rights for Catholic workers and made certain that abstinence programs were not gutted in the fight against AIDS. On January 9, he was told that he had been asked by President-elect Obama to stay on in this job. But as soon as Obama was sworn in, he was thrown out: on January 22, one day after Hillary Clinton was confirmed as secretary of state, he was notified by her staff to find another job. Why? News reports show that Dybul was accused of working too closely with the Catholic Church.”

It remains to be seen if UNAIDS’ encouraging steps toward evidence-based strategies in the fight against AIDS will be followed up on the ground, especially considering the new regime in Washington, which provides a large proportion of Africa’s anti-AIDS aid money. The efforts of Dr. Green and other scientists may finally be bearing fruit. Of course, the Pope and the Church have known this truth all along. We can pray that, for suffering Africans’ sake, those who control most of the world’s aid purse-strings will see the light.

 

 
About the Author
Joseph A. D'Agostino 

 

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