Dirty Little Secret: Why Condoms Will Never Stop AIDS in Africa
by Sue Ellin Browder
Every ten seconds, a man, woman, or child in Africa dies from an AIDS-related disease. According to the USAIDS/World Health Organization (WHO), 40.3 million people now live with HIV infections, two-thirds of them in sub-Saharan Africa. In Swaziland, 42.6 percent of pregnant women test positive for HIV.
There’s no cure for this killer, and no end in sight. The United Nations predicts that if present trends continue, AIDS will claim an additional 65 million lives by 2020—more than triple the number of those who died in the first 20 years of the pandemic.
It has been five years since New York Times columnist Bob Herbert wrote that most of us are simply unable to grasp the enormity of this disaster. “We are in the early stages of an unprecedented threat to the health of the human species,” he warned. “The long dark night of AIDS has just begun.”
Promoting Condoms Without Evidence
In response to this unimaginable tragedy, AIDS experts have long had one simple, first-line solution: Use condoms. Indeed, since 1989, at least 4 billion condoms have been shipped to sub-Saharan African nations in the belief that they’d stem the spread of the disease.
So here’s the surprise: According to the latest research, condom promotion is ineffective for anything but lowering the rate of AIDS in concentrated, high-risk groups, like homosexuals in San Francisco or prostitutes in Bangkok. Condoms have never been shown to reduce HIV infection rates and AIDS deaths in general-population epidemics like those in sub-Saharan Africa. Paradoxically, the more condoms AIDS activists send to Africa, the more widespread the disease has become.
This has not escaped the attention of health researchers. Armed with solid evaluations of the effectiveness of condom promotion programs in sub-Saharan Africa, the world’s most knowledgeable AIDS experts are reaching a new consensus: Condoms have their place, but they’re not the magic bullet scientists once believed them to be. “We need to understand there are different kinds of AIDS epidemics,” says Dr. Edward C. Green, a medical anthropologist and senior research scientist with Harvard’s School of Public Health. What’s more, he adds, “When it comes to AIDS epidemics, one-size-fits-all health prescriptions don’t work. Different types of AIDS epidemics require different solutions.”
In the November 27, 2004, issue of the prestigious British medical journal The Lancet, more than 150 of the world’s leading AIDS scientists and other experts in AIDS prevention and treatment signed a statement in which they declared that “the time has come for common ground” on preventing HIV/AIDS. Of the three interventions scientifically shown to prevent AIDS—abstinence, being faithful, and using condoms—they argue that the use of condoms clearly comes last and should be promoted as a first-line defense only to those in extremely high-risk groups, such as commercial sex workers.
“Fortunately, we can now move beyond debating how well condom promotion might work to examining how well it has worked,” says Dr. Norman Hearst, a family and community medicine professor at the University of California, San Francisco.
The overwhelming conclusion is in: “So far, there’s no good evidence that condoms will reverse population-wide epidemics like those in sub-Saharan Africa,” Dr. Green notes.
The UN estimates that 37 percent of 16-year-olds in Mozambique will die of AIDS before age 30. Faced with such horror, Dr. Green says, “It’s simply not appropriate or effective to offer a 15-year-old girl in Africa the same AIDS-prevention message we give to a 50-year-old gay man or injecting drug user in Baltimore. Contrary to Western stereotypes about African sexual behavior, most 15-year-old African girls are not yet sexually active.”
More Condoms = More AIDS?
Condoms have failed spectacularly. Indeed, contrary to expectations, countries with the most condoms per man tend to have the highest HIV rates.
In South Africa, which has strongly promoted condoms as the best way to prevent AIDS, the number of free condoms distributed to the public rose rapidly between 1994 and 1998, from 6 million to 198 million. Including those sold, the total number of condoms distributed in South Africa during 1998 was nearly 210 million, according to an October 20, 2001, article in the British Medical Journal. Did this giant increase curb the pandemic? On the contrary: Statistics released by South Africa’s government in 2005 revealed that death rates skyrocketed from an average of 870 deaths a day in 1997 to 1,370 deaths a day in 2002—a 57 percent increase. Deaths of individuals ages 15 to 49 (when people are most sexually active) more than doubled, the New York Times reported.
But there is more bad news:
In Botswana, condom sales rose from 1 million to 3 million between 1993 and 2001. Meanwhile, HIV prevalence among urban pregnant women rose from 27 percent to 45 percent.
During the same period in Cameroon, condom sales increased from 6 million to 15 million, while HIV prevalence rose from 3 percent to 9 percent, Dr. Hearst and Sanny Chen reported in the March 2004 Studies in Family Planning.
In Zimbabwe, which Dr. Green notes “has one of the highest condom user rates in Africa,” infection rates were so high by 2002 that UNAIDS experts noted that if present trends continue, by 2020 the country will have lost 30 percent of its work force to AIDS-related diseases.
Malcolm Potts, professor of population and family planning at University of California, Berkeley, wrote in the June 21, 2003, British Medical Journal: “The rapid spread of HIV in sub-Saharan Africa is one of the greatest failures in the history of public health.”
What Went Wrong?
Why has condom promotion failed to make a dent in the sub-Saharan pandemic? Time and again, we’ve been told that condoms are effective in the war against AIDS. The U.S. Food and Drug Administration (FDA) recently came out with yet another statement to this effect, and the headlines trumpeted the news. But exactly how effective are they?
Looking at evidence culled from the best of more than 4,000 studies of HIV-infected individuals sexually active with members of the opposite sex, a recent international Cochrane review concluded that consistent use of condoms may reduce HIV infection by about 80 percent. The review team added, however, that effectiveness against HIV may be “as high as 94.2 percent” or “as low as 35.4 percent.”
Unfortunately, in many regions of Africa, Dr. Green says, the lower number may be more likely. Pointing to the poor quality of condoms often found in tropical Third World nations, he explains, “Quality may deteriorate simply from incorrect or lengthy storage in hot warehouses or on shelves of clinics or shops.”
Let’s assume that condoms are 85 percent effective (the most commonly accepted scientific finding). What does this mean? “It means that if 100 people have sex with HIV-infected partners and they never use condoms, seven of the 100 will become infected within a year. If they always use condoms, one in 100 people will become infected,” explains Dr. Joe S. McIlhaney Jr., chairman of the Medical Institute for Sexual Health in Austin, Texas.
This looks impressive at first glance. But applied to a population of 10 million couples having sex for three years, we’re talking about approximately 300,000 new cases of HIV/AIDS. And that’s assuming perfect condom use, which doesn’t happen in broad populations in real life.
What’s more, the one-in-100 estimate may be too low. In Zambia, doctors gave out condoms and spermicides to 110 couples in which only one partner was HIV-infected. Among couples who said they always used condoms during sex, 2.3 percent of healthy partners became HIV-infected within a year.
When Alfonso López Cardinal Trujillo, president of the Vatican’s Pontifical Council for the Family, said several years ago that trusting in a condom to save one’s life from AIDS is like playing Russian roulette, he was greeted with outrage. “Condom manufacture, supply, and promotion is now a multibillion-dollar-a-year industry,” Dr. Green explains. “Many people are connected to this industry, and they stand to lose billions if less money goes to condoms.” Nevertheless, the cardinal was right.
Even if condoms were perfect, humans are not. Men typically put on condoms incorrectly, puncture them with their fingernails, or damage them while opening the package. The Centers for Disease Control and Prevention found that even among men who used condoms regularly, human error resulted in possible HIV exposure in about 13 percent of sexual acts. And this was among well-educated American men. How much higher would this failure rate be among illiterate young men in rural Africa?
And that’s only if men will use them. According to a study published in 1995 in the International Journal of STD and AIDS, in a survey of 2,285 Tanzanian women, 57.5 percent reported never using condoms because “men did not like them.” A Ugandan youth-group leader told Dr. Green: “The fact remains that sex without a condom does not feel the same as with a condom. Once, twice, thrice with a condom and one time without it. What next? Better sexual feeling and no return to the condom.”
In Africa, condoms are also associated with commercial sex and promiscuity, which gives them a sordid image. Africans are seldom willing to use condoms in steady relationships because doing so would show lack of trust. Dr. Hearst says, “In Nigeria, where polygamy is common, only 2 percent of men said they always use condoms with a spouse or ‘concubine,’ compared with 67 percent who reported using condoms with casual partners.”
In South Africa, where AIDS sufferers are sometimes literally dying in the streets, public-health clinicians gave away thousands of free condoms, then followed the recipients to see what they did with them. Five weeks later, the study (published in the journal AIDS) reports, fewer than half of the condoms (43.7 percent) had been used. The other 56.3 percent had been lost, discarded, given away, or stashed somewhere, possibly (though not definitely) for future use. Of 198 million condoms given away to South Africans in 1999, the study revealed that as many as 111 million may have been lost, unused, given away, or discarded.
Condom marketers often claim that even if condoms aren’t 100 percent effective, they’re better than nothing at all and cost only pennies apiece. But this, too, is false. Population Action International, a private group dedicated to slowing down world population growth, predicts that if present trends continue, by 2015 sub-Saharan Africans will “need” 2.3 billion condoms a year (up from 1.1 billion a year in 2000). The money required to distribute this many condoms and teach people to use them correctly (not to mention the expense of advertising campaigns necessary to overcome resistance to using them) would drastically increase. A review of the evidence published in the May 11, 2002, issue of The Lancet found that, depending on the country, the expense of using condoms to prevent just one case of HIV/AIDS in Africa ranged from $11 to more than $2,000. Poor African nations, where millions are already starving, can hardly afford such a cost.
Is All Hope Lost for Africa?
Amid the unrelenting bad news, there is a bit of hope. While Western AIDS experts have struggled for years in frustration against the sub-Saharan pandemic, Africans themselves have hit upon a simple, cheap, culturally acceptable AIDS-prevention strategy that has reduced HIV-infection rates and saved millions of lives: chastity.
Those AIDS educators and activists still locked in the old paradigm claim that you can’t tell young people to abstain from sex and stay faithful. But in 1986, Uganda’s government launched a program that proved them wrong. To tackle its growing HIV crisis, Uganda initiated an aggressive media campaign that urged adolescents to abstain from sex until marriage, adults to be faithful, and people who absolutely refused to stop having risky sex to then use a condom.
“This ‘ABC’ message [Abstain, Be faithful, or for those who refuse to do either, use Condoms] is the only approach that has ever resulted in a significant decrease in HIV infections in what we call generalized epidemics,” says Dr. Green. Condoms can reduce individual risk—especially for those having sex with HIV-infected people who can’t or won’t abstain. But for uninfected people up to age 19, delaying sex is the most effective message; for people 20 and older, sexual fidelity is the key.
Unpacking the ABC success story in Postgraduate Medical Journal, Dr. Samuel Okware, with the Ministry of Health in Kampala, Uganda, explained: “The three components are closely intertwined, complementing each other in much the same way that all the critical components of a car need to be in place for it to move. None is sufficient on its own and each has contributed to the larger success.”
Once the ABC program was launched, rates of 13- to 16-year-olds having sex in one district of Uganda plummeted from nearly 60 percent in 1994 to less than 5 percent in 2001. Less than 10 percent of unmarried Ugandan women reported multiple partners (compared with 20 percent to 65 percent of women in other African nations, such as Kenya and Malawi). And national HIV infection rates fell between 1992 and 2002, from 21 percent to 6 percent. Dr. Green, who worked for years as a condom marketer and once believed that condoms were the answer, found this success astounding. “It changed my whole perspective,” he says.
Dr. Green notes that much of the media criticism has been aimed at the abstinence element of the program. But Uganda’s main message—for the majority of the population—was not abstinence, but mutual fidelity (or “zero grazing,” to use the local slang). In other words, it was a reduction in casual sex, not the elimination of all sex, that led to Uganda’s plunging HIV rates. Many couples in Uganda are young, married, and highly sexually active. They’re avoiding AIDS not by avoiding sex, but by being faithful to one another.
In the April 30, 2004, issue of Science, Rand L. Stoneburner and Daniel Low-Beer of Cambridge University observed that “Uganda has shown a 70 percent decline in HIV prevalence since the early 1990s, linked to a 60 percent reduction in casual sex.” They noted that this made the reduction of casual sex in Uganda as good as a highly effective vaccine.
Stealing the Success
Now that Uganda has become the classic African AIDS success story, some ABC critics claim that condoms secretly saved the day. And yet, throughout the period when HIV rates decreased most dramatically, condom use in Uganda remained low: “Only 8 percent of all Ugandans between ages 15 and 49 say they used a condom during the last intercourse. And most of that use was probably inconsistent,” Dr. Green says.
Furthermore, the ABC model is working in other African nations. In Kenya before 1999, the major response to AIDS was supplying and promoting condoms—with little or no effect on the pandemic. Finally, the Kenyan government introduced an ABC approach. As Dr. Green reported in the Journal of Medicine and the Person this year, between 1998 and 2003 among never-married people ages 15 to 24, the number of individuals abstaining from sex rose from 44 percent to 59 percent among men and from 68 percent to 79 percent among women. The number of women with multiple partners dropped from 4 percent to 2 percent, while the number among men dropped from 30 percent to 17 percent. Meanwhile, the overall prevalence of HIV in adults went from 10 percent to 6.7 percent.
Recent good news from eastern Zimbabwe suggests that young adults there are also getting the “A” and “B” message. According to a study published in the February 3, 2006, issue of Science, between 1998 and 2003, young adults reported having much less casual sex—a 22 percent drop among women under the age of 25, and a dramatic 49 percent plunge among men under 30. At the same time, HIV prevalence in these age groups fell steeply: by 23 percent in men and 49 percent in women.
The Church and Condoms
Predictably, the Catholic Church has been sharply criticized for opposing condoms—the “C” component in the Ugandan approach—promoted to prostitutes, homosexuals, and injection-drug users. But the Church teaches that all persons are made in God’s image and deserving of love. For individuals in concentrated epidemics, condoms still fail.
In 1989, the Journal of Sex & Marital Therapy revealed the dirty little secret of epidemic control: If homosexuals use condoms, they won’t necessarily be safe as individuals, but at least the rest of society will be protected. And some experts now doubt that condoms reduced HIV rates among gay men in San Francisco. “One careful prospective study showed that for ‘receptive’ men during anal sex, it made little or no difference whether their partners used a condom or not,” says Harvard’s Dr. Green. “The truth is, condoms are even less effective in anal sex than in vaginal sex.” He adds that even in Thailand, where HIV rates plummeted after prostitutes began requiring condoms, “the decline in HIV prevalence during the mid-1990s may have been due to a high percentage of men not going to prostitutes and not having multiple partners.”
The Vatican is currently considering the possibility of allowing condom use among married couples, should one of the spouses have AIDS. If such an allowance is made, it will be based on the Thomistic principle of double effect: The intent of the married couple is not to contracept, but to protect the uninfected partner from a deadly disease. Whether Rome adopts this position is yet to be seen. As of now, no decision has been announced. —S. E. B.
Harm Reduction or Harm Elimination?
There are many common situations where the only way to save lives is to focus on harm reduction. Seatbelts in cars are a good example. The only way to prevent all deaths from car accidents is for people to stop driving. But since that’s not possible, governments do what they can to reduce the risks of driving: setting speed limits and requiring people to wear seatbelts.
There are other situations, however, where the threat of death is so serious that the risk must be completely eliminated. Consider this hypothetical situation: If 42 percent of pregnant women in the United States were, for whatever mysterious reason, suddenly dying from riding in cars, public health officials would likely caution pregnant women to stay out of cars. They wouldn’t just urge them to wear seatbelts.
In the case of cigarettes, Big Tobacco focused for decades on harm reduction. But when smoking was finally found to increase the risk of incurable lung cancer by a whopping 1,400 percent and to contribute to many other diseases, public-health campaigns shifted to harm elimination. The clear public-health message became “Don’t smoke,” and “If you do smoke, quit.” No one advised smokers simply to reduce the harm of smoking by using filters, lighting up fewer cigarettes, or eating more oranges.
When it comes to AIDS in Africa, condoms are a risk-reduction technology, much like seatbelts or cigarette filters. “Abstain from sex if you’re single” and “Be faithful if you’re married” are risk-elimination strategies. Dr. W. Henry Mosley of the Johns Hopkins Bloomberg School of Public Health points out that “it should be intuitively obvious that if young persons abstain from sexual activity until establishing a permanent partnership, and if both partners are faithful in their sexual union, the risk of acquiring HIV is zero. Protection is 100 percent.”
“When dealing with a fatal, incurable disease like AIDS, wouldn’t we all prefer risk elimination for our own kids?” Dr. Green asks.
Stressing that premarital and extramarital sex are far riskier for sub-Saharan Africans than smoking is, Dr. McIlhaney says, “Smoking rarely hurts kids while they’re still adolescents, but sexual activity can give them AIDS before they’re even out of their teenage years.” He adds that just as lung cancer isn’t caused by the way one smokes, but by the fact that one smokes, AIDS is not caused by the way one has sex, but by the fact that one has sex with an HIV carrier. “Sub-Saharan Africans, first and foremost, need accurate information. They need to be told the true risks of condoms and not to be falsely assured that if they just use condoms they can do whatever they please and everything will be okay.”
The medical evidence is clear: A condoms-for-all approach won’t stem a population-wide AIDS epidemic. Nearly all the world’s top AIDS scientists—at least those who have no commercial or ideological conflicts of interest to hide—are coming to agree on this point.
Yet few journalists specialize in health reporting, and fewer still diligently read the medical literature. As a result, the media (caught up in the old paradigm) often over- emphasize news favoring condoms. As one example, when a conference paper—presented at one well-publicized meeting in Boston—questioned abstinence and monogamy as the reason for Uganda’s success, this news swept through the global media like wildfire. “Uganda’s HIV rate drops, but not from abstinence: Study concludes basis of Bush policy apparently irrelevant,” a San Francisco Chronicle headline read. In fact, this single study was preliminary, unpublished, and valid only for one district in southern Uganda. Meanwhile, far weightier evidence drawn from high-quality, peer-reviewed studies published in reputable journals that shows the effectiveness of abstinence and fidelity is routinely downplayed or ignored.
Adding to the confusion, the AIDS-in-Africa story is commonly misframed as an intensely polarized “culture war” between “religion” (said to want abstinence only) and “science” (said to want condoms). But, in fact, the true conflict is between an old scientific hypothesis (condoms will save the day) and a new medical-evidence-based understanding: The only surefire way to prevent AIDS in general-population epidemics is to urge people to abstain or be faithful to their spouses; condoms should be offered only as a last resort to those unwilling to do A or B. That’s not religion, but rather a verified, recent, scientific finding.
By 2020, the global death toll from AIDS is predicted to be 85 million, threatening to make this scourge deadlier than the Black Death and the Holocaust combined.
Do we truly love our African brothers and sisters? Do we sincerely respect their civil liberties, including the right to receive accurate information, the right to make love without fear of AIDS, and the right to live past 30? Will we collectively continue to defend the economic interests of the condom companies at the expense of the African people? Or will we unite in truth behind science-based medical evidence?
Forty-two African AIDS victims have died since you started reading this article. There’s no time to lose.
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Sue Ellin Browder is a veteran investigative reporter who has won seven medical journalism awards and a Project Censored Award—for “the news that didn’t make the news”—for her article “Deadly Doctors.” She is a longtime contributor to Reader’s Digest and many other national publications. This article reproduced with permission from Crisis Magazine.
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