‘Evidence of Science’ Backs Pope’s Assertion Against Condom Use To Stem HIV-AIDS in Africa

Susan E. Wills
By Susan E. Wills | March 2, 2010 | 8:09 AM EST

Last March, Harry Knox, who serves on the President’s Advisory Council on Faith-Based and Neighborhood Partnerships, criticized Pope Benedict XVI for his comment that the African AIDS epidemic will not be overcome by promoting condoms.

Knox wrote that Pope Benedict was “hurting people in the name of Jesus,” adding that “on a continent where millions of people are infected with HIV, it is morally reprehensible to spread such blatant falsehoods.”

Recently a reporter asked Knox if he stood by his statement – he indicated that he emphatically does – even in light of the strong defense of Pope Benedict by Harvard AIDS expert Edward Green.

In responding to the reporter, Knox tried to discredit Green’s research: “He is simply incorrect in his assertion. All other evidence of science shows otherwise.”

But an honest review of the “evidence of science” clearly shows that Pope Benedict’s  observation finds solid support in studies by dozens of  experts published in peer-reviewed journals in the past decade.
It’s a mystery why people place so much faith in condoms. Even with “perfect use” condoms can rip or slip, but “typical use” entails still greater risk.

Then there’s the issue of cumulative risk, the sobering fact that the risk associated with a single use is magnified with multiple exposures. Here’s a simple illustration: The odds of getting heads in one coin toss are 50 percent. But toss a coin five times and the odds of getting heads once increase to 97 percent.

The same holds true for acquiring an STD. With one exposure to a partner with human papillomavirus (HPV), the risk of transmission is 50 percent; with five exposures, the risk is 97 percent.

“Risk compensation” also contributes to condom ineffectiveness. Writing in the British Medical Journal in 2006, Michael Cassell et al., explain: “The perception that using condoms can reduce the risk of HIV infection may have contributed to increases in inconsistent use, which has minimal protective effect, as well as to a possible neglect of the risks of having multiple sexual partners.

Thus, the protective effect of promoting condoms may be attenuated at the population level and could even be offset by aggregate increases in risky sexual behavior.”

What works in combating an AIDS epidemic?

In 2004, some 150 experts signed a Comment in The Lancet calling for an evidence-based approach to preventing the sexual transmission of HIV/AIDS with primary emphasis on behavior modification in generalized epidemics.

The lead authors, Daniel Halperin et al., prioritize interventions according to their effectiveness: “When targeting young people … the first priority should be to encourage abstinence or delay of sexual onset. … After sexual debut, returning to abstinence or being mutually faithful with an uninfected partner are the most effective ways of avoiding infection.”

They continue, “When targeting sexually active adults, the first priority should be to promote mutual fidelity with an uninfected partner as the best way to assure avoidance of HIV infection. The experience of countries where HIV has declined suggests that partner reduction is of central epidemiological importance in achieving large-scale HIV-incidence reduction.”

The consensus of these AIDS experts was not reached on the basis of one article, but on numerous studies, some of which are summarized in “Condoms and AIDS: Is the Pope Right or Just ‘Horrifically Ignorant’?” Linacre Quarterly (February 2010).

T. Stammers (2005) writes: “There are no examples to date from any country in the world that has reversed a generalized HIV epidemic by means of condom promotion alone.”

Stammers compares the HIV prevalence at prenatal clinics in Uganda, where condom use in the early-mid 1990s was negligible, to prevalence at prenatal clinics in South Africa, where condoms have been promoted as the principle means of HIV prevention. Between 1991 and 1998, HIV prevalence at 15 Ugandan prenatal clinics declined from 18.5 percent to 9.7 percent. Prevalence was found to be only 7.4 percent by 2001-2002 at nine Ugandan prenatal clinics evaluated in a second study (Asamoah-Odei et al., 2003).

Contrast this success with South Africa, where the prevalence of HIV among pregnant women rose to 25.7 percent in 2001-2002 from 19.9 percent in 1997-1998 (Ibid.).

R. Stoneburner and D. Low-Beer (2004) note that “despite limited resources, Uganda has shown a 70-percent decline in HIV prevalence since the early 1990s, linked to a 60-percent reduction in casual sex.… [Whereas, despite] substantial condom use and promotion of biomedical approaches, other African countries have shown neither similar behavioral responses nor HIV prevalence declines of the same scale.”

James Shelton, a USAID senior medical scientist, co-authored a 2004 study in the British Medical Journal explaining the “crucial role” of partner reduction in reducing HIV/AIDS transmission. Key to Uganda’s success is that “the proportion of men with one or more casual partners in the previous year fell from 35 percent in 1989 to 15 percent in 1995, and the proportion of women from 16 percent to 6 percent.”

John Stover et al. (2008) reviewed trends in HIV prevalence in Botswana: “Condom use in Botswana is among the highest anywhere in the world. … [But the] proportion of adults with more than one sexual partner remains very high. A high level of partner concurrency contributes to rapid reproduction of new infections.”

It would seem that Pope Benedict and Dr. Green are correct, and it is Mr. Knox who should take a more honest look at the “evidence of science.”