Tuesday, April 1, 2008

A Punch in the Gut to the Condom Racket

There's a devastating critique of primarily condom-based AIDS prevention programs in Africa in the current issue of First Things ("AIDS and the Churches: Getting the Story Right").

It's also worth noting that one of the authors of said article, Edward Green, is a knuckle-dragging Neanderthal who never went to college an anti-gay Bible-thumping preacher the director of the AIDS Prevention Research Project at the Harvard Center for Population and Development Studies; the other author, Allison Herling Ruark, is a research fellow there.

Of particular note from the article:

Consider this fact: In every African country in which HIV infections have declined, this decline has been associated with a decrease in the proportion of men and women reporting more than one sex partner over the course of a year—which is exactly what fidelity programs promote. The same association with HIV decline cannot be said for condom use, coverage of HIV testing, treatment for curable sexually transmitted infections, provision of antiretroviral drugs, or any other intervention or behavior. The other behavior that has often been associated with a decline in HIV prevalence is a decrease in premarital sex among young people.

If AIDS prevention is to be based on evidence rather than ideology or bias, then fidelity and abstinence programs need to be at the center of programs for general populations. Outside Uganda, we have few good models of how to promote fidelity, since attempts to advocate deep changes in behavior have been almost entirely absent from programs supported by the major Western donors and by AIDS celebrities. Yet Christian churches—indeed, most faith communities—have a comparative advantage in promoting the needed types of behavior change, since these behaviors conform to their moral, ethical, and scriptural teachings. What the churches are inclined to do anyway turns out to be what works best in AIDS prevention.


In fact, the mainstream HIV/AIDS community has continued to champion condom use as critical in all types of HIV epidemics, in spite of the evidence. While high rates of condom use have contributed to fewer infections in some high-risk populations (prostitutes in concentrated epidemics, for instance), the situation among Africa’s general populations remains much different. It has been clearly established that few people outside a handful of high-risk groups use condoms consistently, no matter how vigorously condoms are promoted. Inconsistent condom usage is ineffective—and actually associated with higher HIV infection rates due to “risk compensation,” the tendency to take more sexual risks out of a false sense of personal safety that comes with using condoms some of the time. A UNAIDS-commissioned 2004 review of evidence for condom use concluded, “There are no definite examples yet of generalized epidemics that have been turned back by prevention programs based primarily on ­condom promotion.” A 2000 article in The Lancet similarly stated, “Massive increases in condom use world-wide have not translated into demonstrably improved HIV control in the great majority of countries where they have occurred.”


Thus far, research has produced no evidence that condom promotion—or indeed any of the range of risk-reduction interventions popular with donors—has had the desired impact on HIV-infection rates at a population level in high-prevalence generalized epidemics. This is true for treatment of sexually ­transmitted infections, voluntary counseling and ­testing, diaphragm use, use of experimental vaginal microbicides, safer-sex counseling, and even income-­generation projects. The interventions relying on these measures have failed to decrease HIV-infection rates, whether implemented singly or as a package. One recent randomized, controlled trial in Zimbabwe found that even possible synergies that might be achieved through “integrated implementation” of “control strategies” had no impact in slowing new infections at the population level. In fact, in this trial there was a somewhat higher rate of new infections in the intervention group compared to the control group.


Meanwhile, the other interventions that have generally been called “best practices” simply do not seem to work in generalized epidemics, even though they are still applauded loudly at global AIDS conferences, while mention of fidelity and abstinence is received by booing, as Bill Gates discovered at the International AIDS Conference in Toronto in 2006. If we are to progress beyond science-by-popular-acclaim, we must accept that the evidence is much stronger for fidelity or partner reduction than for any of the standard-package HIV-prevention measures—in Africa at least—and so we need to rethink and reprogram AIDS-prevention interventions.

Admittedly, changing direction is hard when there has been massive investment in these “best practices.” It is not in the interest of a multibillion-dollar global AIDS industry to endorse interventions that are low-cost and homegrown and that rely on simple behavior change rather than medical products or services provided by outside experts. And so the major donors of AIDS programs continue to do the same things, expecting different results.

Ah, yes— the Bullwinkle approach.

Some people just never learn:

1 comment:

Stuart said...

When I read an article that makes those with opposing beliefs look foolish, and seamlessly supports my own convictions, I experience mixed emotions. On the one hand, there is some pleasure in that. But it is a guilty pleasure, because there is the sneaking feeling that what I am reading is 'too good to be true.' That is what I get out of Green's article. He makes some good points, but also simplifies the Ugandan situation somewhat, and does not point out that reduction of concurrency -- rather than fidelity to one partner or abstinence -- may have had the biggest impact. (Perhaps because 'reduction of concurrency' is compatible with serial infidelity) Taking aim at condom campaigns is alright up to a point -- the big money wheel isn't condoms anyway -- the real money pit is vaccines and microbicides. Ach, too good to be true ... Cheers, Stuart