Day 54: Pope Benedict XVI, condoms and AIDS

Pope Benedict XVI really stirred the pot yesterday, with his comments about condoms not working to prevent AIDS. I was tipped off by a few of my Facebook friends, who had not very nice things to say about the Pope in the wake of his words.

The Joint United Nations Programme on HIV/AIDS was apparently so rattled that they put out a statement today, reiterating that condoms are a “critical element” in worldwide HIV/AIDS prevention.

Here’s what the Pope actually said, while talking to reporters on a plane bound for Camaroon: ”One cannot overcome the problem with the distribution of condoms. On the contrary, they increase the problem.” 

According to a Catholic News Service story, that statement was part of a larger message.

The Pope also said:

The solution can only be a double one: first, a humanization of sexuality, that is, a spiritual human renewal that brings with it a new way of behaving with one another; second, a true friendship even and especially with those who suffer, and a willingness to make personal sacrifices and to be with the suffering. And these are factors that help and that result in real and visible progress.

And you know what? On a spiritual level, I agree with him. I think the same goes for any major challenge facing the world. Whether it’s worldwide carbon emissions, human rights violations or hunger, the only real progress is going to come from shifts in consciousness, the willing engagement of large numbers of people that I dare say will include elements of goodwill, love and concern for others. Without that, few solutions can really grow legs. 

But this isn’t a spiritual blog; it’s a science blog! And of course, when I heard the Pope’s comments about the effectiveness of condoms, I got curious about whether he might be right.

Most of us have seen the numbers in sex ed classes, on condom packages or from our doctors: when used properly, latex condoms are more than 98 percent effective at preventing the spread of AIDS. 

Ninety-eight percent is pretty good. But that’s not what the Pope meant.

Studies are few and far between that actually track the success of condom distribution at reducing the spread of HIV. The Bulletin of the World Health Organization noted this in a 2004 report: 

The question remains whether programmes designed to increase the frequency of condom use actually achieve increased use and whether they decrease the individual’s risk of acquiring HIV and other STIs. Many studies have shown that condom-promotion interventions decrease self-reports of unprotected sex, but fewer have examined the impact of such programmes on the actual incidence of STIs, including HIV infection. 

There have been a few notable findings over the years. And all of them seem to point to the idea that throwing condoms at people is not a sole solution. With or without condoms, people seem to be responding — and AIDS seems to be waning — where the outreach has been personal and educational, and even moral, in nature. 

It seems that in the very least, people need to be coached about consistent condom use. When organizations distribute condoms, and then people don’t consistently use them, the money and effort is wasted. (See a 2001 study in the Journal of the International AIDS Society.)

A July 2007 study in the American Journal of Public Health found a combined strategy worked well in South Africa: making condoms available while emphasizing personal behavior choice. 

“Condom use at sexual debut and talking with one’s first sexual partner about condoms were the most significant predictors of condom use,” that study found. (Interestingly, another predictor was “optimism about the future.”)

And then there’s Uganda. Apparently the tale has sparked many debates about what strategy can take credit for the drastic reduction in HIV there between the late 1980s and the mid-1990s. To me, it looks like a pretty heartwarming story about community-wide, heartfelt, positive change. Here’s a synopsis, which borrows liberally from a 2006 study in the journal AIDS and Behavior.

At the height of the epidemic, 15 percent of adults across the country were infected. By 2003, only 4 percent were infected. Surveys by the WHO’s Global Program on AIDS also reported these dramatic statistics:

*the proportion of single males ages 15–24 reporting premarital sex decreased from 60 percent in 1989 to 23 percent in 1995

*people reporting casual sex in the previous year dropped from 35 to 15 percent among men, and from 16 to 6 percent among women.

*the proportion of males reporting three or more non-regular partners fell dramatically.

So, what worked? Well, a little bit of everything. Almost everything.

Head of state President Yoweri Museveni made a proactive commitment to prevention. In face-to-face interactions with Ugandans at all levels, he emphasized that fighting AIDS was a “patriotic duty” requiring openness, communication and strong leadership from the village level to the State House. He encouraged constant and candid national media coverage of all aspects of the epidemic, emphasizing behavior change.

Churches got involved, with priests and preachers using Sunday services and even funerals and weddings to put out the message about responsible sexual behaviors. Organizations worked to empower youths and women. The country hosted one of the world’s first anonymous testing and counseling centers, where people could get same-day results. 

Condoms were not part of this solution. 

The first edition of a Uganda government handbook on AIDS prevention advised, “The government does not recommend using condoms as a way to fight AIDS, and a 2004 analysis of the situation concluded that the initial antipathy toward condoms might, ironically, have helped promote more fundamental changes in behavior: “In Uganda, the fact that condoms were not initially introduced and also the president’s negative attitude towards them, played a part in the social acceptance of sexual behavioral change messages.” Lead author Tim Allen, of the London School of Economics and Political Science, and his co-author wrote that the use of condoms may have actually backfired in a separate anti-AIDS effort in Botswana.

And so it seems that, scientifically speaking, the Pope has a solid leg to stand on. Certainly I don’t have a moral issue with condoms. The Pope didn’t claim one either during his talk with reporters, and in fact the Catholic News Service says the church is currently debating its morality stance on the use of condoms in AIDS prevention efforts.

But what’s sure is the very type of outreach the Pope is seeking to do — without condoms — has been demonstrated very clearly to work.