Friday, March 20, 2009

Are condoms useless to fight aids?

The Pope has gotten a lot of trouble from a recent speech when he said that AIDS was "a tragedy that cannot be overcome by money alone, that cannot be overcome through the distribution of condoms, which even aggravates the problems".

The NYT got it right when they condemned the comments, saying that, while the first part is true, "there is no evidence that condom use is aggravating the epidemic and considerable evidence that condoms, though no panacea, can be helpful in many circumstances".

I was confused though by the general work of Daniel Halperin and Helen Epstein. But this is not their message.

In an article in Science magazine, Daniel Halperin, along with his coauthors, argues that:
Condom promotion is effective in epidemics spread mainly through sex work, as in Thailand and also, to some extent, among other high-risk groups such as MSM. Although condom use has also likely contributed to HIV decline in some generalized epidemics, there is no evidence of a primary role. This is because consistent condom use has not reached a sufficiently high level, even after many years of widespread and often aggressive promotion, to produce a measurable slowing of new infections in the generalized epidemics of Sub-Saharan Africa. When most transmission occurs within more regular and, typically, concurrent partnerships, consistent condom use is exceedingly difficult to maintain.
Yes, condoms alone don't work, but Halperin is clearly arguing that this is partly due to a lack of consistent use.

While I respect Easterly greatly, when he does things like rant against multidisciplinarism and argues that there is a "Condom Mafia", I begin to have serious doubts.

1 comment:

Joseph Bolin said...

The Pope didn't say that condoms absolutely can't decrease the problem, but that they don't. Dr. Edward Green, the Director of the AIDS Prevention Research Project at the Harvard School of Public Health and Center for Population and Development Studies, agrees with him. He sees it as partly a result of "risk compensation"--people feel safer with condoms, and so they take more risks.

Dr. Edward Green is a medical anthropologist with 30 years of experience in developing countries and in the fight against AIDS.

The following is from an interview with him: [Source]

The Pope’s statement about AIDS and condoms is at the centre of a sharp debate and many – from Mr. Kouchner to Mr. Zapatero, including the EU Commission – have claimed his position to be abstract and eventually dangerous. What is your opinion ?

I am a liberal on social issues and it’s difficult to admit, but the Pope is indeed right. The best evidence we have shows that condoms do not work as an intervention intended to reduce HIV infection rates, in Africa. (They have worked in e.g. Thailand and Cambodia, which have very different epidemics)

In a recent interview to NRO you said that there is no consistent association between condom use and lower HIV-infection rates. Could you deepen this point?

What we see in fact is an association between greater condom use and higher infection rates. We don’t know all the reasons for this but part of it is due to what we call risk compensation. This means that a man using condoms believes that they are more effective than they really are, and so he ends up taking greater sexual risks. Another fact which is widely overlooked is that condoms are used when people are engaging in casual or commercial sex. People don’t use condoms with spouses or regular partners. So if condom rates go up, it may be that we are seeing an increase of casual sex.

So, even if it is surprising, it is proven that a higher use of condoms is associated with higher infection rates.

People began noticing years ago that the countries in Africa with the highest condom availability and highest condom user rates, also had the highest HIV infection rates. This does not prove a causal relation, but it should have made us look critically at our condom programs years ago.