Monday, March 08, 2010

Incorrectly Splitting Hairs

In his letter to the NYTimes, the Archbishop of New York cites Harvard's Dr. Green:

An otherwise perceptive column was somewhat scarred by two comments: recent work by experts like Dr. Edward Green of the Harvard School of Public Health, and experience in countries like Uganda, lead many to conclude that dependence upon only condoms to control H.I.V.-AIDS is dangerous policy, making Mr. Kristof’s comments about the Vatican (“whose hostility to condoms contributes to the AIDS epidemic”) unjust.

The Archbishop's conclusion is not really a valid one. Read Dr Green's letter to The Lancet, titled "Was the Pope Wrong" (provided below). I don't think anyone has been advocating for "condoms alone" as the complete strategy for ending the spread of HIV. It is not the condom that is inefficient, but rather the inconsistent use of it. That same aspect of human nature that makes abstinence fail as a way to stop HIV also makes condoms fail: the fact that people sometimes do dumb things when driven by sexual desire. Abstinence is a daunting challenge. Always using a condom is a daunting challenge. Note that Dr. Green talks about "partner reduction" as a more successful strategy. Understandable, and if all the world's leaders proclaimed 2010 as a year in which nobody will have sex in order to slow the spread of HIV, partnering and HIV would be reduced, right? Because everybody would follow that prescription, right?

Note that Dr. Green is not saying that condoms should be withheld from Africans.

The Archbishop of New York has perhaps not thought about the fact that if he or his predecessors had distributed condoms to the many priests who have died of AIDS over the last three decades or if the bishops had made preventive confidential counseling available to those priests along with condoms, the current shortage of priests would be alleviated considerably.  The number of priests who have died from AIDS has never been correctly reported for two reasons: the families of those priests almost always were ashamed of the fact and preferred to list an opportunistic disease such as pneumonia or cancer as the cause of death. The bishops did not want the faithful to know that priests are gay and sexually active. If the bishops were more courageous, Christlike and compassionate, they would have reached out the families of priests victimized by AIDS and to the gay clergy rather than become complicit in denial. We may also never know the number of men who have died because they contracted the virus from a Catholic priest.

I think any sensible bishop should attend to his own house before he starts spouting opinions about HIV in Africa, and that includes the German Shepherd who is the Bishop of Rome where he presides over a male prostitution ring operating within the walls of his own palace. I wonder how many choristers and seminarians involved in that business are HIV positive.

Was the Pope wrong?

The Lancet published an Editorial1 condemning comments Pope Benedict gave on a trip to Africa, calling them “outrageous and wildly inaccurate.” The Pope said he thought money alone could not solve the problem; moreover “If there is no human dimension, if Africans do not help by responsible behaviour, the problem cannot be overcome by the distribution of prophylactics: on the contrary, they increase it.” Notice the construction: ifno responsible sexual behaviour (or primary prevention) then condom distribution will not overcome risky sexual behaviour, which is surely the case in Africa's generalised HIV epidemics.
Ecological and epidemiological evidence from generalised epidemics points to partner reduction as the primary behavioural factor explaining declines in HIV prevalence, which we now see in several African countries. Increased condom availability or use has not shown a similar pattern of association with prevalence decline across multiple generalised epidemics.23
Could condom promotion exacerbate epidemics? The phenomenon of risk compensation—engaging in higher-risk behaviours because risk reduction technology conveys a greater sense of safety than warranted—could account for higher infection rates,4 and has been suggested by at least one randomised, controlled study, which found that “gains in condom use seem to have been offset by increases in the number of sex partners.”5
The root of the problem is that people do not use condoms consistently, no matter how they are promoted. A little bit of condom use might be like a little bit of antibiotic use—not ultimately helpful.
We declare that we have no conflicts of interest.


1 The LancetRedemption for the Pope?Lancet 20093731054Full Text | PDF(82KB) CrossRef | PubMed
2 Potts MHalperin DTKirby D, et alPublic health: reassessing HIV preventionScience 2008320749-750.CrossRef | PubMed
3 Green ECHearst NMah THerling-Ruark AA framework of sexual partnerships: risks and implications for HIV prevention in AfricaStud Fam Plann 20094063-70CrossRef | PubMed
4 Cassell MMHalperin DTShelton JDStanton DRisk compensation: the Achilles' heel of innovations in HIV prevention?BMJ 2006332605-607PubMed
5 Kajubi PKamya MKamya SChen SMcFarland WHearst NIncreasing condom use without reducing HIV risk: results of a controlled community trial in UgandaJ Acquir Immune Defic Syndr 20054077-82CrossRef | PubMed
a Harvard Center for Population and Development Studies, 9 Bow Street, Cambridge, MA 02138, USA
b University of California, San Francisco, CA, USA

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