The Pope, Condoms, and AIDS

Sundry blogger and pundit have been raking the Pope over the coals for the past day for his comments on AIDs and condoms. A New York Times editorial this morning summarizes the basic complaint:

Pope Benedict XVI has every right to express his opposition to the use of condoms on moral grounds, in accordance with the official stance of the Roman Catholic Church. But he deserves no credence when he distorts scientific findings about the value of condoms in slowing the spread of the AIDS virus.

As reported on Tuesday by journalists who accompanied the pope on his flight to Africa, Benedict said that distribution of condoms would not resolve the AIDS problem but, on the contrary, would aggravate or increase it. The first half of his statement is clearly right. Condoms alone won’t stop the spread of H.I.V., the virus that causes AIDS. Campaigns to reduce the number of sexual partners, safer-sex practices and other programs are needed to bring the disease to heel.

But the second half of his statement is grievously wrong. There is no evidence that condom use is aggravating the epidemic and considerable evidence that condoms, though no panacea, can be helpful in many circumstances.

No one, of course, would accuse the New York Times of playing politics with science, but let’s consider what the experts say.

Edward C. Green, the director of the AIDS Prevention Research Project at the Harvard Center for Population and Development Studies, and Allison Herling Ruark, a research fellow at the Center, wrote just one year ago in First Things :

In fact, the mainstream HIV/AIDS community has continued to champion condom use as critical in all types of HIV epidemics, in spite of the evidence. While high rates of condom use have contributed to fewer infections in some high-risk populations (prostitutes in concentrated epidemics, for instance), the situation among Africa’s general populations remains much different. It has been clearly established that few people outside a handful of high-risk groups use condoms consistently, no matter how vigorously condoms are promoted. Inconsistent condom usage is ineffective—and actually associated with higher HIV infection rates due to “risk compensation,” the tendency to take more sexual risks out of a false sense of personal safety that comes with using condoms some of the time. A UNAIDS-commissioned 2004 review of evidence for condom use concluded, “There are no definite examples yet of generalized epidemics that have been turned back by prevention programs based primarily on ­condom promotion.” A 2000 article in The Lancet similarly stated, “Massive increases in condom use world-wide have not translated into demonstrably improved HIV control in the great majority of countries where they have occurred.”

Faith communities are not shutting their eyes to evidence when they choose to emphasize the “core recommended strategy of abstinence before marriage and faithfulness within marriage.” These behaviors have, in fact, proved far more effective than condom use in curbing HIV transmission for the vast majority of any population. A 2001 study of condom use in rural Uganda found that only 4.4 percent of the population reported consistent usage in the previous year, a rate that is probably typical of much of Africa. In contrast to the estimated 95 percent or more of Africans who did not practice consistent condom use in the past year, studies from all over Africa show a solid majority of men and women reporting fidelity over the past year, with a majority of unmarried young men and women reporting abstinence.

. . .

Thus far, research has produced no evidence that condom promotion—or indeed any of the range of risk-reduction interventions popular with donors—has had the desired impact on HIV-infection rates at a population level in high-prevalence generalized epidemics. This is true for treatment of sexually ­transmitted infections, voluntary counseling and ­testing, diaphragm use, use of experimental vaginal microbicides, safer-sex counseling, and even income-­generation projects. The interventions relying on these measures have failed to decrease HIV-infection rates, whether implemented singly or as a package. One recent randomized, controlled trial in Zimbabwe found that even possible synergies that might be achieved through “integrated implementation” of “control strategies” had no impact in slowing new infections at the population level. In fact, in this trial there was a somewhat higher rate of new infections in the intervention group compared to the control group.