Condom talk

Yes, I'm late to the party in commenting on the Pope and Pell and their comments on condoms in Africa.

I'm finally prompted to do so by an article yesterday in The Age by a couple of Australian AIDS researchers who cited various studies that they say do not support the Pope's view.

Yet, they spend a lot of time in explaining the success of condoms in non-African countries, particularly those where the widespread use of prostitutes has been at the core of the problem. This is not exactly the same situation as in much of Africa. (You can read the Green article I cite below in support of that.) And besides which, if you could actually pin down Pell on the moral effect of a man visiting a prostitute using a condom, would he say that it compounds the sin, or would he allow that using one reduces the potential bad consequences and, if not a good thing, is at least morally neutral? (I admit he would probably be reluctant to answer, given that he doesn't want in any way to encourage people towards sexual immorality in the first place.)

There's the same missing-the-point in much of David Marr's spray in last weekend's Sydney Morning Herald. He talks of the success of condoms in reducing HIV in Australia - where it was always largely a problem in the gay community. Funny, but I have never noticed the Catholic bishops spending a lot of time teaching that gay men should not use condoms. Even for the heterosexual, I'm always a bit puzzled as to why people think that Catholics who are willing to sin sexually are still going to consider themselves bound by one related issue of Catholic teaching while in the act.

Anyway, the main point of this post is to point people who have not already read him to a Harvard AIDS researcher Edward Green. He wrote an opinion piece in the Washington Post entitled "The Pope may be right", but his views appear to have attracted no attention in the Australian media. Here's a key paragraph:

In 2003, Norman Hearst and Sanny Chen of the University of California conducted a condom effectiveness study for the United Nations' AIDS program and found no evidence of condoms working as a primary HIV-prevention measure in Africa. UNAIDS quietly disowned the study. (The authors eventually managed to publish their findings in the quarterly Studies in Family Planning.) Since then, major articles in other peer-reviewed journals such as the Lancet, Science and BMJ have confirmed that condoms have not worked as a primary intervention in the population-wide epidemics of Africa. In a 2008 article in Science called "Reassessing HIV Prevention" 10 AIDS experts concluded that "consistent condom use has not reached a sufficiently high level, even after many years of widespread and often aggressive promotion, to produce a measurable slowing of new infections in the generalized epidemics of Sub-Saharan Africa."

And why does he think it hasn't worked well in Africa as it has in other countries:

One reason is "risk compensation." That is, when people think they're made safe by using condoms at least some of the time, they actually engage in riskier sex.

So, the Pope and Pell have at least one high profile HIV researcher pretty much on their side. People should at least know that.

When I pointed this out at Harry Clarke's blog, he responded by suggesting that Green was just pushing his Catholic faith. I don't know if he is a practising Catholic or not, but he describes himself as a liberal, and certainly he is not saying condoms should be banned:

Don't misunderstand me; I am not anti-condom. All people should have full access to condoms, and condoms should always be a backup strategy for those who will not or cannot remain in a mutually faithful relationship. This was a key point in a 2004 "consensus statement" published and endorsed by some 150 global AIDS experts, including representatives the United Nations, World Health Organization and World Bank. These experts also affirmed that for sexually active adults, the first priority should be to promote mutual fidelity. Moreover, liberals and conservatives agree that condoms cannot address challenges that remain critical in Africa such as cross-generational sex, gender inequality and an end to domestic violence, rape and sexual coercion.

Here's an interview Green gave to the BBC recently. There you can read this snippet which more directly supports the Pell line on risk compensation in Africa:

There was one where--Norman Hurst of the University of California was one of the authors, it was published in the journal Aids--where they followed two groups of young people in Uganda, and the group that had the intensive condom promotion--and they were provided condoms after three years--they actually were found to have a greater number of sex partners. So that cancels out the risk reduction that the technology of condoms ought to provide. That's the phenomenon known as risk compensation.

Interestingly, in The Age article I initially referred to, they cited the decrease in use of prostitutes in Thailand (where condom use in brothels is very high) as evidence against the risk compensation theory. That may be true in Thailand, but it raises another issue: how much can you say that it is the widespread use of condoms that is the reason for the reduction in HIV spread there, as compared to the pretty dramatic drop in the use of prostitutes in the first place? Seems to me they just want to concentrate on the condom effect, without giving credit to decreased promiscuity.

Here is a long article of Green's that appeared last year in the religious journal First Things. Well worth reading. He disputes the re-interpretation of the Ugandan experience that The Age article notes.

It seems pretty clear that the matter of appropriate responses to HIV in Africa is the subject of some controversy within academia. It's even clear that there is at least some evidence supporting the idea of risk compensation in Africa. The Pope and Pell are not completely out on a limb here when they talk about the African experience, not that you would know that from most of the media coverage.

UPDATE: I just found this commentary at Eureka Street, arguing again that the context of the African experience of AIDS is important:

In contrast to the Western world, religious congregations and parishes were extensively involved from the beginning in caring for infected and rejected women and children. The local Catholic sisters, priests and many bishops generally recognised the dilemma and some have spoken against an absolute interdiction of condoms.

But they also recognise that the instrumental and value free programs imported from the West were less effective in Africa. The spread of AIDS had cultural roots that also needed to be addressed. A view of marriage in which the woman was more than an object, the eradication of magical views of the causes and protections against AIDS, and a culture of mutual respect and of faithfulness within marriage, were required if AIDS was to be checked. These touched the consideration of human sexuality enshrined in church teaching.

The whole article is worth reading.

UPDATE 2: another interesting take on all of this is at The Alligator.