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Health experts worldwide, as well as a fair share of editorial pages, have inveighed against Pope Benedict XVI's comments on AIDS, that condoms make the epidemic worse, a little bomb he dropped on reporters earlier this month on a plane heading for Africa.
"You can't resolve it with the distribution of condoms," the pope said of the AIDS crisis. "On the contrary, it increases the problem."
The Lancet, a prestigious medical journal, most recently chimed in with an editorial in its March 28 issue, stating that the pontiff distorted scientific evidence to promote Catholic doctrine.
Benedict, as usual, isn't particularly concerned about any uproar his comments bring. It's not as if he's running for re-election. And yet while there's some merit in his abstinence-focused approach to slowing HIV's spread, the data he draws upon continues to be misinterpreted.
A church divided
Surprisingly, the Vatican has no authoritative policy on condom and HIV. Benedict hasn't issued an encyclical, or papal letter, informing the Holy See of the church's official stance on this matter.
Benedict's predecessors issued encyclicals affirming that condoms cannot be used for contraception; this is "intrinsically evil," Pope John Paul II had said. But, according to many Catholic bishops, the commandment "thou shall not kill" trumps any sin of adultery or thwarted conception. This leaves some wiggle room for an HIV-infected husband to use a condom with his wife if she is not ovulating.
Some liberal church leaders see condom use as the lesser of two evils: That is, premarital sex with a condom is a lesser sin than sex without it. Nonetheless, the Vatican clearly favors abstinence and marital fidelity.
The Uganda success story
Promoters of abstinence-focused HIV-prevention strategies, including the pope, point to Uganda's success in reducing HIV prevalence. While HIV rates climbed in neighboring countries, the proportion of Ugandans infected with HIV plunged from 21 percent in 1991 to 6 percent in 2002.
The success is attributed to the ABC campaign, short for "Abstain, or Be Faithful, or use Condoms." Conservative commentators often reference a Washington Post column from June 2008 by Sam Ruteikara, co-chair of Uganda's National AIDS-Prevention Committee, in which he states that the casual-sex Western agenda forced upon his country in recent years threatens to undermine the success of its homegrown solution.
But Ruteikara, a man of the cloth, and others touting Uganda's success fail to acknowledge Uganda's own data of what actually happened during those years. There's a C in ABC.
As reported in 2006 in the British Medical Journal's Sexually Transmitted Infections, Ugandan government health officials found that the rate of "ever use" condoms rose from 1 percent to 16 percent among women and from 16 percent to 40 percent in men from 1989 to 2000. Condom use during the most recent sexual encounter with a non-regular partner increased from 35 percent to 59 percent among men and 20 percent to 39 percent among women.
There was no change in the rate of extramarital sex among men. Rates of premarital sex fell, but abstinence programs weren't emphasized; they constituted the A in ABC but weren't the first feature of the campaign.
Studies published in the journal Science in 2004 and elsewhere uncovered the reason for ABC's success, a personal connection to AIDS. Over 80 percent of Ugandan women had heard of AIDS from a personal source, not from some foreign health worker. This is up to twice the rate compared to neighboring countries. Also, far more so than their neighbors, 91.5 percent of men and 86.4 percent of women knew someone with AIDS, prompting behavior change. Sadly, death contributed to the perceived decline in prevalence.
2009 reality check
Catholic leaders also like to point to the Philippines, where both condom use and HIV prevalence is low. In this largely Catholic country — and in many Muslim countries, for that matter — abstinence and fidelity might work (although not among prostitutes). But HIV rates are also low in Japan, were pre- and extramarital sex is common but condoms are the primary means of birth control.
Abstinence always has been the most effective means for any individual to avoid being infected with HIV. This has been the official stance of every health agency since the dawn of AIDS. Condoms are not 100-percent effective against HIV; the failure rate is as high as 10 percent due to improper use, comparable (and often better) than the failure rate of many of our best vaccines against various diseases. This, too, has been the official stance of all health agencies. No one is saying sex with a condom is safer than abstinence.
Yet, as with imperfect vaccines against disease, the success of condom use in curbing HIV infection in, say, Brazil, parts of southeast Asia and even in the United States, particularly among male homosexuals, is irrefutable. The most revealing studies are of couples where one is infected and the other is not, protected by condom use.
Conversely, there is no convincing evidence that condom-use advocacy promotes sexual promiscuity. Here the pope wasn't misinterpreting data but perhaps just making it up. Given the clear success condoms have had, it seems that saying they are not only ineffective but detrimental borders on sinfulness.
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