The media has put Pope Benedict and the Catholic Church in its sights over AIDS and condoms. But who does the science actually back?
By Deirdre Fleming
“Blind faith trumping common sense,” “Vatican insiders declare the Pope a disaster,” “Outrageous,” “Irresponsible” …If anything is embarrassing, it is the sensationalism of such statements in the Western media when giving the party line of anti-Catholic sentiment. The trouble is that when one looks at the science of AIDS research today, one finds a completely different story from the one being promoted by the popular media.
Whose expert opinion?
The problem for the layman is that certain organisations which sound authoritative make claims which are regarded as “expert opinions.”
For example, the International Aids Society has denounced Pope Benedict XVI’s comments as “contrary to scientific evidence and global consensus” and has suggested that his comments might even exacerbate HIV infection in Africa.
In the same vein, the president of the World Health Assembly, Leslie Ramsammy, has claimed, “The statement by the Pope is inconsistent with science, it’s inconsistent with our experiences and it is not in sync with what Catholics have experienced and believe4,” while Kevin Osborne of the International Planned Parenthood Federation says, “All the evidence is that preaching sexual abstinence and fidelity will not solve the problems …The Pope’s message will alienate everybody. It is scary. It spreads stigma and creates a fertile breeding ground for the spread of HIV.”
On the other hand, authorities in the field who disagree with these sorts of statements get scant media attention. Here I am not talking about renegade scientists, but professionals in HIV/AIDS research who provide technical reports to the World Health Organisation (WHO) and The Joint United Nations Program on HIV/AIDS (UNAIDS).
Take, for example, Edward Green, director of Harvard University’s Aids Prevention Research Project (APRP): in an interview with CNA, Green stated with reference to Africa (see also, story at left), “Theoretically, condoms ought to work, and theoretically, some condom use ought to be better than no condom use, but that’s theoretically … We just cannot find an association between more condom use and lower HIV infection rates.
This view is echoed by Helen Epstein, specialist in public health in developing countries and consultant to Human Rights Watch. In a 2008 letter to UNAIDS she bemoans the disconnect between on-the-ground research about condoms and UN reports: “I seem to recall UNAIDS documents attributing the decline in HIV infections in US gay men to the rise of ‘the condom culture’. In fact, modeling studies by Martina Morris and behavioural surveys carried out across the US show that partner reduction was dramatic during the 1980s, when HIV decline among gays was the steepest. The “condom culture” emerged only later. I can provide many references on this, on request.” She goes on to say, “Condom use alone may have protected many individuals, but has not – in the absence of partner reduction – shown a strong epidemiological effect, anywhere. One may not like this fact, but it is true.”
Condoms, though seemingly an effective technological fix, have had their greatest influence in AIDS prevention when targeted towards such areas as the sex industry in Thailand.
But even then, the UNAIDS best practice reports fail to mention that there was a 60 per cent decline in visits to brothels during Thailand’s condom campaign and that this undoubtedly contributed to the decline in HIV.8
Why are condoms
The trouble with condoms is that they have the effect of giving users a false sense of security which results in disinhibition, that is, users indulge in greater risk taking which eventually negates any protective effects of the condom.
According to Potts et al., “When most transmission occurs within more regular and, typically, concurrent partnerships, consistent condom use is exceedingly difficult to maintain.”
James Shelton of the Bureau for Global Health, USAID, in Washington DC puts it this way: “Many people dislike using them (especially in regular relationships), protection is imperfect, use is often irregular, and condoms seem to foster disinhibition, in which people engage in risky sex either with condoms or with the intention of using condoms.”
“Condom use with prostitutes and in one-night stands is increasingly the norm all over the world, but they are rarely used in longer-term, less businesslike affairs,” observes Helen Epstein.
Know your epidemic
It is becoming increasingly clear to AIDS researchers that some of the assumptions that underlie HIV prevention strategies are unsupported by the evidence.
Some of the confusion is created by a failure to differentiate adequately between different types of epidemics. Outside of Africa (in Europe, the Americas, Middle East, Asia and Australasia) HIV tends to occur among high risk groups: Men who have sex with men, injecting drug users, sex workers and their partners.
These are known as concentrated epidemics. Africa, particularly Southern and Eastern Africa, on the other hand, is an example of a generalised epidemic, with infection predominantly heterosexual and generalised among the population.
Then there are epidemics such as those in the Caribbean, Pacific region, the horn of Africa and West Africa which may include characteristics of both concentrated and generalised epidemics.
According to James Shelton ten myths impede the success of AIDS prevention in Africa (see box). These misconceptions include beliefs such as that poverty and conflict increase vulnerability to HIV and that transmission occurs through sex workers and promiscuous men or adolescents; whereas current research seems to indicate that most transmission occurs because of the prevalence of multiple and simultaneous or concurrent partnerships among adults in African society.
Helen Epstein describes it this way in her article, The Fidelity Fix: “This ‘concurrency’ links sexually active people up in a giant network, not only to one another but also to the partners of their partners’ partners – and to the partners of those partners, and so on – via a web of sexual relationships that can extend across huge regions. If one member contracts HIV, then everyone else in the web may, too.” Helen Epstein and Daniel Halperin of Harvard’s Centre for Population and Development Studies explain it this way: “In Africa, many longer term relationships that do not involve prostitution nevertheless tend to have a powerful ‘transactional’ element. People with more disposable income might thus be able to maintain multiple, concurrent relationships. Although very few are ‘rich’ by Western standards, they are nevertheless at the leading edge of the massive social and economic transition occurring in Africa today, from an agrarian past to a semi-industrialised present, characterised by rapid urbanisation, high unemployment, and lack of social security. As with all such transitions, this creates upheavals in basic norms, customs and values, which might facilitate the spread of HIV.”
In an opinion piece for The Lancet, James Shelton states, “Our priority must be on the key driver of generalised epidemics – concurrent partnerships… But partner limitation (fidelity) has also been neglected because of the culture wars between advocates of condoms and advocates of abstinence, because it smacks of moralising, because mass behavioural change is alien to most medical professionals, and because of the competing priorities of HIV programs.
David Wilson of World Bank and Daniel Halperin of the Harvard School of Public Health agree.
“For too long, the global HIV-prevention community has pursued generalised responses in concentrated epidemics, concentrated approaches in generalised epidemics, or hedged their bets and done a bit of everything,” they said in The Lancet in August 2008.
“For example, after three decades, the global community is only beginning to accept that there is no simple direct association between income, education, gender inequality, and HIV. Population-based surveys show that the wealthier African countries have the highest, not the lowest, infection levels in Africa, and more educated, upper-income people are generally more likely to be infected with HIV.”
They say that it is “striking that a comparison of gender equality and HIV prevalence across African countries shows a strong positive, not negative, association.” That is, wherever women and men are most equal, HIV is most prevalent. Contrast Botswana, the second wealthiest country in Africa, with rare male circumcision, high levels of multiple concurrent partnerships and an HIV prevalence of 25 per cent, with Niger, the lowest ranking country in the Human Development Index, predominantly Muslim with strict sexual constraints and universal male circumcision, but an HIV prevalence of 0.7 per cent.
“Turning to generalised epidemics” continue Wilson and Halperin, “we face three overarching challenges. First, our most trusted prevention interventions – testing and counselling, condom promotion, school and youth programs, and treatment of other sexually transmitted infections … are at best unproven, and at worst disproven, for reducing HIV incidence. Second, the most solidly proven preventive intervention to date, male circumcision, is barely advancing … In countries such as Sambia, with 15 per cent adult HIV prevalence and nearly US$1billion in aid annually for AIDS, much less than 1 per cent of this funding goes for male circumcision services … Third, the major contributor to reduced HIV transmission in generalised epidemics has been reduction in multiple sexual partnerships (increased fidelity). Compelling evidence of this association has emerged in a growing number of African countries, such as Kenya, Zimbabwe and Ethiopia. Additionally, partner reduction seems to have contributed to HIV declines in Haiti and the Dominican Republic. Yet, except for Uganda in the late 1980s, and more recently in Swasiland, reductions in multiple partnerships seem to have mainly occurred despite, not because of, formal programs.”
What happened in Uganda
In 1993, Helen Epstein was working as a molecular biologist in Uganda, at that time the country with the highest HIV-infection rate in the world. She explains how HIV incidence plummeted from 21 per cent in 1991 to six per cent in 2002.
“At the time, few international health experts were working on AIDS in Uganda, but the Ugandan government developed a simple and effective program on its own. In 1986, the Uganda Ministry of Health started a vigorous HIV-prevention campaign in which the slogans ‘Love Carefully,’ ‘Love Faithfully” and ‘Sero Grasing’ – Ugandan slang for ‘Don’t have sexual partners outside the home’ – were posted on public buildings, broadcast on radio and bellowed in speeches by government officials, teachers and AIDS-prevention workers across the country.
“Religious leaders scoured the Bible and the Koran for quotations about infidelity. Newspapers, theatres, singing groups and ordinary people spread the same message.Their words fell on fertile ground … A realistic fear of AIDS was reinforced by a compassionate response to the suffering the disease created. Ordinary Ugandans have always been much more open about AIDS than people from other African countries, and they were also far more likely to admit that they knew someone who had died of the disease or was infected with HIV. Community- and church-based groups sprang up to help families affected by AIDS. Uganda’s women’s movement, one of the oldest and most dynamic in Africa, galvanised around issues of domestic abuse, rape and HIV.
“The anger of the activists, and the eloquent sorrow of women throughout the country who nursed the sick and helped neighbours cope, was a harsh reproach to promiscuous men. So was their gossip, a highly efficient method of spreading any public-health message.”
An article by Potts et al. in Science explains it as follows: “In Uganda, HIV prevalence declined dramatically following the extensive “Sero Grasing” campaign of the late 1980s. WHO surveys conducted in 1989 and 1995 found a greater than 50 per cent reduction in the number of people reporting multiple and casual partners. In Kenya, partner reduction and fidelity also appear to have been the main behavioural change associated with the recent HIV decline.
“Similar behaviour change has been reported in DHS surveys in Simbabwe, where HIV has also fallen, along with Ethiopia, Cote d’Ivoire, and urban Malawi. In Swasiland, the number of people reporting two or more partners in the past month was halved after an aggressive 2006 campaign focusing on the danger of having a ‘secret lover’.”
Reassessing the funding
Potts and his team plead for a reassessment of funding for interventions that have the greatest potential impact.
In a letter responding to comments by the Department of Evidence, Monitoring and Policy at UNAIDS, they say, “We note that the requested funding for [hyper-endemic and generalised] epidemics would comprise only a little over 20 per cent of the global total, even though such epidemics account for over two-thirds of all HIV infections worldwide.
“Also, although 5 per cent of this funding would be dedicated to circumcision programs, the large majority of resources would continue to be allocated to other interventions, for which the evidence of prevention impact in generalised epidemics is much weaker … Recent CDC data from Uganda suggest that most married people who recently acquired HIV were infected by an extramarital partner or by their spouse who had recently acquired HIV from an extramarital partner. Many of the latter were probably in the brief “acute infection” period, when HIV infectivity is much higher yet undetectable by a standard HIV test. It is crucial to address the multiple and concurrent partnerships that mainly drive these generalised epidemics.” A growing number of AIDS experts who are prepared to look at the facts are questioning why the Ugandan approach has not been emphasised in Southern Africa and elsewhere. Edward Green in his book Rethinking AIDS Prevention says,
“There is also a troubling suspicion among a growing number of scientists who support the ABC model that certain opponents may simply be AIDS profiteers, more interested in protecting their incomes than battling the disease.”
His book, Aids and Ideology, due for release later this year highlights the AIDS funding industry which is “drawing billions of dollars a year promoting condoms, testing, drugs and treatment of AIDS.”6
Claiming that AIDS has been spread because of the lack of human rights for “vulnerable populations”, such as homosexual men and sex workers, the UN, in the document International Guidelines on HIVAIDS and Human Rights, have suggested that AIDS cannot be defeated unless all international laws restricting human sexuality are amended:
“Criminal law prohibiting sexual acts (including adultery, sodomy, fornication and commercial sexual encounters) between consenting adults in private should be reviewed, with the aim of repeal.”
The Guidelines also promote abortion on demand, legalisation of homosexual marriage, and laws “providing penalties for vilification of people who engage in same-sex relationships.”
It seems that to the UN, AIDS funding is more about promoting the ideologies of the sexual revolution than about using the research to promote public health.
“To treat one AIDS patient with life-prolonging anti-retroviral drugs costs more than US$1,000 a year. Our successful ABC campaign cost just 29 cents per person each year,” explains Sam Ruteikara, co-chair of Uganda’s AIDS Prevention Committee.
David Kalema, Ugandan AIDS activist, puts it poignantly in the film The Change is On, which documents the Catholic Church’s approach to behaviour modification in South Africa and Uganda:
“Maybe they tried [abstinence] and it failed, and since it failed with them, they think it will fail with everyone. I’m a testimony myself. I finished my primary [school] without having sex. I went for my secondary education, I didn’t have sex, I went to University, I was not having sex. I never fell sick because of not having sex. Can this world tell me that it only worked with me? The way it worked with me it can work with everyone else. My friends who used to laugh at me thinking that abstinence is abnormal, most of them are dead by now.”
Deirdre Fleming is a former Science Educator, and is currently undertaking Postgraduate Studies in Public Health at Curtin University
The 10 myths about Generalised HIV epidemics:
HIV spreads like wildfire.
Prostitution is the problem.
Men are to blame.
Poverty and discrimination are to blame.
Condoms are the answer.
HIV testing reduces HIV incidence.
Treatment will stop the spread of AIDS.
New technology is the answer.
Sexual behaviour will not change.
1. HIV is most infectious in the initial weeks when virus levels are high, but detection is not yet possible.
2. Of more importance are simultaneous (concurrent) long-term relationships, both formal, as in polygamy, and informal.
3. Although men’s behaviour is important, women having multiple partners are a significant contributor.
4. Epidemics span all reproductive ages. HIV incidence increases in women in their twenties and older.
5. The world’s highest HIV prevalence occurs in countries with greater wealth and literacy, such as Botswana (25%) and Swaziland, while countries such as Rwanda, Angola and Congo, known for episodes of conflict, genocide and rape have been much less affected.
6. There is no consistent relationship between condom use and the decline of a generalized epidemic.
7. There is no evidence that HIV testing has turned an epidemic around.
8. Treatment seems to lead to disinhibition rather than stopping new infections.
9. New technology is expensive and engenders a false sense of security.
10. Evidence is mounting that behaviour change is possible and has already happened in some areas.
Source: Shelton J, Ten myths and one truth about generalised HIV epidemics (2007), The Lancet, Vol. 370, p. 1809