AIDS, Condoms, and Africa

By Michael Bayly

Father Giuseppe Caramazza’s recent argument that “The Catholic Church is Right: The Condom is No Cure for AIDS in Africa” sounds very similar to Dr. Edward C. Green’s. Green, the director of the AIDS Prevention Research Project at the Harvard Center for Population and Development Studies, is frequently cited by those who support the Vatican’s view that condoms are non-effective in preventing the spread of HIV/AIDS. For instance, in an article in the National Review, Dr. Green declared: “We have found no consistent associations between condom use and lower HIV-infection rates, which, 25 years into the pandemic, we should be seeing if this intervention was working.” Green made this comment in response to Pope Benedict’s remarks on the effectiveness of condoms earlier this year.

“The pope is correct,” said Green, “or put it a better way, the best evidence we have supports the pope’s comments.” He stresses that “condoms have been proven to not be effective at the ‘level of population.’”

The BBC’s William Crawley, has the following to say about Dr. Green and the complex issue of AIDS and condom use. (Note: I've added the emphasis in certain parts of the text).

Writes Crawley:

Dr. Green is sometimes described as an AIDS researcher in press coverage. We should be clear about his area of expertise. He holds a PhD in Anthropology from the Catholic University of America and studies public health strategies “at the level of population.” He is not a medical doctor, nor is he a virologist, nor is he an epidemiologist. He is a widely-respected academic who examines the impact of various public health strategies in various populations.

In 2003, he published a book, Rethinking AIDS Prevention, which challenged the general approach to AIDS preventing in the developing world. Specifically, he argued that the most successful strategy for preventing the spread of HIV in Africa was not the distribution of condoms but campaigns encouraging people to reduce their number of sexual partners. Monogamy was a powerful behavioural defence against HIV, he said. Condoms, though technically able to prevent the spread of HIV when used correctly, have failed, according to Dr Green. Why have they failed? According to Pope Benedict, condoms encourage promiscuity and this drives the AIDS pandemic. According to Dr Green – who has no moral or religious objection to the use of condoms – this strategy in Africa has had the counter-effect of encouraging people to engage in riskier behaviour while believing that they are protected by condoms. “This may be due in part to a phenomenon known as risk compensation, meaning that when one uses a risk-reduction ‘technology’ such as condoms, one often loses the benefit (reduction in risk) by ‘compensating’ or taking greater chances than one would take without the risk-reduction technology,” he says.

These conclusions led Dr Green to change his view on the usefulness of condoms in Africa. Notice that he maintains their usefulness in other parts of the world, such as the United States; he regards Africa as a special case for cultural reasons. [Interestingly, Caramazza also admits that condoms may work in places outside Africa.]

. . . The upshot is that [unlike the Pope, and presumably Fr. Caramazza] Dr Green strongly supports the ABC model in HIV prevention: “Abstain, Be faithful, or use Condoms if A and B are not practiced”. In the same year that Rethinking AIDS was published, Dr Green was appointed by George W Bush's Advisory Presidential Council on HIV and AIDS.

It is vital that we have a serious debate about HIV prevention and that we locate that debate geographically and culturally. It is wrong at the outset to simply assume that an HIV prevention model that works in the United States or Europe would necessarily work in sub-Saharan Africa. Researchers who believe condoms are an effective strategy represent the majority position within the HIV prevention community.

Against Dr Green’s concerns about “risk compensation,”, they argue that this points to a greater need for accompanying education programmes explaining the proper use of condoms and challenging risky behaviour.

The UN AIDS programme accepts – who wouldn't? – that “other components [of a successful HIV prevention strategy] include delay of sexual initiation, abstinence, being mutually faithful to each other when both partners are uninfected, and reducing the number of sexual partners.” But the UN emphasises that condoms still play a very significant role and their promotion must be culturally sensitive: “Condoms must be promoted in ways that help overcome sexual and personal obstacles to their use. Complex gender and cultural factors can be a challenge for HIV prevention education and condom promotion. Due to gender norms and inequalities, young girls and women are regularly and repeatedly denied information about, and access to, condoms, and often they do not have the power to negotiate the use of condoms.”

Against Dr Green’s [and Fr. Caramazza’s] claims that condoms have been ineffective in countries such as Uganda, the World Health Organisation maintains that “recent analysis of the AIDS epidemic in Uganda has confirmed that increased condom use, in conjunction with delay in age of first sexual intercourse and reduction of sexual partners, was an important factor in the decline of HIV prevalence in the 1990s.” This statement references a 2003 research paper exploring the Ugandan experience, “The Roles of Abstinence, Monogamy and Condom Use in HIV Decline.” published by The Alan Guttmacher Institute in Washington DC. (Read the paper in full here.)

This analysis concludes that “positive behavior change in all three areas of ABC - abstinence, being faithful (monogamy) and condom use - have contributed to the decline of HIV in Uganda to sustained lower levels.” It’s a long way from that statement to the claim that condoms are making the problem of AIDS worse.

To read Crawley’s article, “The Pope and Condoms,” in its entirety, click here.