Condoms, the Pope & Africa
The Catholic Church's opposition to condom use has long been a target of AIDS activists. I recall a friend of mine arguing that Pope John Paul II was responsible for the deaths of millions of people in the developing worth who had died of AIDS.
"Why is the pope responsible? I asked, somewhat bemused.
"Because he rejects the use of condoms," my friend replied. "So if some guy is infected with AIDS, he won't use a condom with his wife, and then she'll become infected."
"But the pope is also opposed to adultery," I told my friend. "if that guy won't follow the pope on adultery, why would he pay any attention to John Paul regarding condom use?' My friend agreed I had a point.

Today, the New York Times takes Pope Benedict XVI to task for arguing that a condom campaigns designed to curb the spread of HIV/AIDs may actually increase it.

"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."

What, exactly, did Pope Benedict says about the use of condoms? Fox News reports that the pontiff said something quite simple: "You can't resolve it [HIV/AIDS] with the distribution of condoms," the pontiff told reporters abroad the Alitalia plane headed to Yaounde, Cameroon. "On the contrary, it increases the problem."

In fact, though you wouldn't know if from reading the New York Times, the jury is out regarding the efficacy of condom use to curb the HIV/AIDS infection rate in Africa.

Here's a National Review piece about one expert's decision to challenge the establishment line on HIV/AIDS prevention. "Rethinking AIDs Prevention: Learning from Successes in Developing Countries" by Edward C. Green, senior research scientist at the Harvard Center for Population and Development Studies, suggests that the entire field of AIDS prevention needs to be thoroughly deconstructed. First, he argues that the promotion of condoms in Africa has actually increased the spread of AIDS, and that the majority of Africans need to hear a public health message that emphasizes behavior change.

Last year, in First Things, Green made the additional observation that faith-based efforts have been--and should be part of the solution:

"If AIDS prevention is to be based on evidence rather than ideology or bias, then fidelity and abstinence programs need to be at the center of programs for general populations. Outside Uganda, we have few good models of how to promote fidelity, since attempts to advocate deep changes in behavior have been almost entirely absent from programs supported by the major Western donors and by AIDS celebrities. Yet Christian churches—indeed, most faith communities—have a comparative advantage in promoting the needed types of behavior change, since these behaviors conform to their moral, ethical, and scriptural teachings. What the churches are inclined to do anyway turns out to be what works best in AIDS prevention."

If condoms don't work, why do AIDS experts continue to maintain the condom drumbeat? According to Green the early decision to make condom promotion the centerpiece of an AIDS prevention campaign arose from the fact that the initial outbreak of the virus in the West occurred in a hedonistic gay community: condom promotion was the only option. According to Green, that community was deeply resistant to alternative messages regarding abstinence and monogamy.

The situation on the ground in Africa, however, incorporates a radically different mindset and social context. While heavy condom promotion may be the only -- if imperfect -- option for individuals engaging in high risk behavior, such as prostitutes and their clients, the typical African is free to consider other choices -- including abstinence and monogamy.

Dr. Norman Hearst, Professor of Family Medicine and Epidemiology at the University of California, San Francisco explored this issue at a 2007 hearing at the House Committee on Foreign Affairs. Dr. Hearst summarized the results of a recent study on the relationship between condom use and public health outcomes in both high risk groups and in people caught up in a "generalized epidemic"-- as in much of Africa. Here is what he said:

"We then looked at whether condom promotion has been successful as a public health strategy – something very different from individual effectiveness. Here we found good evidence for effectiveness in concentrated epidemics. For example, condoms made an important contribution to controlling HIV among gay men in places like San Francisco and epidemics driven by commercial sex in places like Thailand.

"We then looked for evidence of a public health impact for condoms in generalized epidemics. To our surprise, we couldn’t find any. No generalized HIV epidemic has ever been rolled back by a prevention strategy based primarily on condoms. Instead, the few successes in turning around generalized HIV epidemics, such as in Uganda, were achieved not through condoms but by getting people to change their sexual behavior."

Hearst reports that his findings have been confirmed in other studies:

"These are not just our conclusions. A recent consensus statement in The Lancet was endorsed by 150 AIDS experts, including Nobel laureates, the president of Uganda, and officials of most international AIDS organizations. This statement endorses the ABC approach to AIDS prevention: Abstinence, Be faithful, and Condoms. It goes further. It says that in generalized epidemics, the priority for adults should be B (limiting one’s number of partners). The priority for young people should be A (not starting sexual activity too soon.) C (condoms) should be the main emphasis only in settings of concentrated transmission, like commercial sex.

Halperin DT, Steiner MJ, Cassell MM, Green EC, Hearst N, Kirby D, Gayle HD, Cates W. The time has come for common ground on preventing sexual transmission of HIV. Lancet 2004; 364: 1913-1915."

Postscript: Here's an article published in the British left-wing paper, The Guardian that provides a surprisingly balanced view of the pope's remarks and the conclusions of studies on AIDS prevention. One point in this article is that even if research trials proved that condoms were effective in curbing the transmission of AIDS, the reality is that access to condoms is sharply limited in poor countries, while behavior change is actually more manageable.

National Review Online posted a great article explaining the Pope's/church's thinking on condoms.