What’s wrong with promoting condoms to stop AIDS?
Billions of condoms have been shipped to Africa in order to prevent the spread of HIV. However, countries that have relied on such “protection” to curb the epidemic are not seeing any great decline in the virus.
One nation that clearly demonstrates this problem is Botswana. For over a decade Botswana has relied upon widespread availability of condoms in order to combat AIDS. Campaigns for abstinence and fidelity were not emphasized. Instead, billboards about “safe sex” lined the streets, while schoolchildren learned songs about condoms. According to The Washington Post, “The anti-AIDS partnership between the Bill & Melinda Gates Foundation and drugmaker Merck budgeted $13.5 million for condom promotion – 25 times the amount dedicated to curbing dangerous sexual behavior. But soaring rates of condom use have not brought down high HIV rates. Instead, they rose together, until both were among the highest in Africa.”
Unfortunately, Botswana was not the only nation to make this mistake. The journal Studies in Family Planning pointed this out in their article “Condom Promotion for AIDS Prevention in the Developing World: Is It Working?” Its authors noted that “in many sub-Saharan African countries, high HIV transmission rates have continued despite high rates of condom use… No clear examples have emerged yet of a country that has turned back a generalized epidemic primarily by means of condom promotion.”
The Uganda example
However, there is a clear example of an African nation turning back the epidemic of AIDS by other means. In the late 1980s Uganda was viewed as the worst nation in the world in terms of HIV/AIDS infections. In 1991, 22 percent of people in the country were infected with HIV. By 1999 the number had dropped to 6 percent. Ugandan President Yoweri Museveni insists that their unique success among African countries is due to their behavioral approach. He said, “In comparison with other countries per capita expenditure on condoms, we spend far below other developed countries, which emphasize use of condoms in their fight against the disease.” Instead of placing the primary emphasis on condoms, they emphasized abstinence and faithfulness first. As a result, they have experienced the greatest decline in HIV in the world. According to the Journal of International Development, it was “the lack of condom promotion during the 1980s and early 1990s [that] contributed to the relative success of behavior change strategies in Uganda.”
Some “safer sex” advocates attempted to claim credit for the success of Uganda’s AIDS decline. But Dr. Edward Green, a Harvard senior research scientist, ruled out such a connection, since “Uganda shows a significant decline in STDs in the absence of a male condom prevalence rate over 5 [percent].” In fact, condoms were not widely used in Uganda until after much of the HIV decline had already taken place. The real reason for the drop in HIV is that between 1989 and 1995 casual sex in Uganda declined by 65 percent.
Some of the sharpest declines took place within the teenage population, which the experts said “took many of us by surprise, since we believed that teenagers are driven by ‘raging hormones,’ therefore abstinence is an unrealistic or impossible objective.” In the words of Dr. Green, who has over two decades of experience in Africa and had previously advocated widespread condom distribution, “Weren’t ‘we’ supposed to teach ‘them’ how to prevent AIDS?”
Unfortunately, the success in Uganda has been undermined in recent years. According to The Washington Post, “The Ugandan turnaround was well underway by the time foreign AIDS experts began to arrive in the early 1990s, bringing with them the Western public health approaches—and values. They began to retool Uganda’s AIDS prevention efforts away from abstinence and fidelity—goals that many Westerners felt were unrealistic. As condom use increased, the percentage of young singles having sex rose from 27 percent to 37 percent between 1995 and 2000.” It seems that only sex-saturated Westerners (who have no handle on their own STD epidemics) are naive enough to expect that condoms will solve the AIDS problem.
“Many of us in the AIDS and public health communities didn’t believe that abstinence or delay, and faithfulness, were realistic goals. It now seems we were wrong.”
Some people ridicule the idea that abstinence education is a realistic way to deal with the AIDS crisis in developing nations. However, the evidence in favour of such an approach is becoming increasingly difficult to ignore. In his testimony before the U.S. House of Representatives, Dr. Green said, “Many of us in the AIDS and public health communities didn’t believe that abstinence or delay, and faithfulness, were realistic goals. It now seems we were wrong.”
In a Washington Post article entitled “Let Africans Decide How to Fight AIDS,” he added, “Billions of dollars and the lives of countless men, women, and children will be wasted if ideology trumps proven health policy.” Lest anyone think that such an emphasis on abstinence is the result of conservative religious leaders placing their ideologies above science, Green noted, “I’m a flaming liberal, don’t go to church, never voted for a Republican in my life.”
His appreciation for the effectiveness of promoting abstinence comes from witnessing its results. Had South Africa implemented Uganda’s emphasis on self-control, one scientist noted, “3.2 million lives would be saved between 2000 and 2010.” The effectiveness of the Ugandan approach has led scientists to consider it a “social vaccine” against HIV.
Why is the behavioural approach more effective?
Why has the behavioural approach of reducing sexual partners been so much more effective than condom distribution? There are a number of reasons.
One reason is that most people do not use the condom consistently and correctly, even after being given sex education. In one study of over five hundred couples who were repeatedly advised by their clinicians to use condoms, only 8 percent of them used it consistently, despite the fact that they knew one partner had herpes and the other did not! In studies of relationships where one partner was infected with HIV and the other was not, only about 50 percent of them always used a condom! If those couples were not motivated enough to use the condom consistently, it’s hard to imagine that perfect condom use will ever be seen in the general population.
In the presence of an epidemic, unless a person changes his or her behaviour, it may be only a matter of time before he or she is infected.
Some might assume, “Well, at least some protection is better than none.” This would seem to be a logical argument. After all, condom use can reduce the odds of HIV transmission during an act of intercourse. However, one study of over seventeen thousand people in Africa showed that inconsistent condom use was not protective against HIV. In the presence of an epidemic, unless a person changes his or her behaviour, it may be only a matter of time before he or she is infected. For this reason Dr. Norman Hearst said that he feared that we are “raising a generation of young people in Africa that believe that condoms will prevent HIV.” While condoms may reduce the risk of HIV transmission, they do not “protect” against AIDS. When people are not taught the difference and are left thinking that risk reduction equals protection, they are more open to taking risks that they cannot afford.
A second reason why the “safe sex” message has failed to curb AIDS is that the “protection” offered by the condom decreases with repeated exposures. A study funded by the Centers for Disease Control followed sexually active young women (most of whom had a steady boyfriend) to assess condom effectiveness over time. The study found that those who used condoms consistently and correctly were not statistically less likely to acquire at least one STD than the girls who used condoms inconsistently or not at all. According to Dr. J. Thomas Fitch, “This study illustrates what happens over time with numerous acts of sex with an infected partner even when a condom is used.”
Similar observations have been seen in Africa. Edward Green remarked, “Twenty years into the pandemic there is no evidence that more condoms leads to less AIDS… Over a lifetime, it is the number of sexual partners [that matter]. Condom levels are found to be non-determining of HIV infection levels.”
A third reason why condoms have failed to stop AIDS is that when a person is infected with other STDs, they are up to five times as likely to get HIV if exposed. There are several reasons why this occurs. One reason is that many STDs cause sores that can serve as portals of entry for the virus. For example, a woman’s reproductive tract is often able to protect her from HIV. However, this natural barrier is compromised when she is infected with certain STDs. Considering that the number one determinant of STD infection is multiple sexual partners, any strategy to stop HIV that does not reduce sexual activity will have limited effect. This is why one AIDS researcher remarked that safe sex “has not been safe in the UK, and in Africa it has been positively dangerous.”
One final reason why condoms have not stopped HIV is that those who are promiscuous more easily catch the virus. In fact, there would be a massive decline in the sexual transmission of HIV if people practiced six months of abstinence between sexual partners. This statement might sound absurd to anyone unfamiliar with the infectivity rates of HIV. The infectivity rate of a disease or virus measures the likelihood of its transmission. For HIV it is estimated to be .001, meaning that, on average, the odds of being infected with HIV through a single act of intercourse (without a condom) is about one in a thousand. However, when a person is first infected with HIV, he or she is highly contagious. If this person were to get tested for HIV right away, the test would show that he or she is HIV negative, despite the fact that he or she does have the virus and can easily transmit it!
Here’s why: Technically the HIV test does not look for HIV, but for antibodies against the virus. Antibodies are what your body produces to fight off intruders. But viruses are smart and they are often able to avoid being detected. HIV can hide in your body for months before your immune system recognizes it (and years before you know of it). So if your body does not know that you have been infected with HIV, it won’t produce antibodies to attack the virus. According to Dr. Harvey Elder, a professor of HIV/AIDS Epidemiology and Care, “The patient’s ‘HIV’ test becomes positive 4–24 weeks after exposure.” But if the HIV test doesn’t find the antibodies, the doctors will tell you that you’re HIV negative.
Meanwhile, inside the body of a newly infected person, the HIV plasma viral level is very high, especially in the genital fluids (semen and cervical-vaginal fluids), because antibodies haven’t been produced to reduce their levels. Since the viral load is extremely high, and the person is shedding viruses, the infectivity rate soars in the early weeks of infection. Dr. Harvey continued, “During the first few months, a person infects 20–30 percent of sexual contacts but [the] HIV test is negative. When the test is positive, 0.2–0.3 percent of sexual contacts become infected [if there are no other STDs present].” This means that if people abstained from sex at least six months between partners, the odds of HIV transmission would be decimated. Therefore, countries that encourage monogamy and self control enjoy much greater success in preventing HIV than countries that simply hand out condoms.
The Philippines vs Thailand
A key example of this is in the Philippines, where condoms are rare, and so is HIV. A New York Times article entitled “Low Rate of AIDS Virus in Philippines Is a Puzzle” reported that the Church in the Philippines is “conservative and politically powerful.” As a result, “the government has no AIDS-awareness program of its own and restricts the public campaigns of independent family-planning groups.”  But, the article reported, “public health officials say they are stumped by a paradox in the Philippines, where a very low rate of condom use [4 percent] and a very low rate of HIV infection seem to be going hand in hand.”
In this conservative Catholic country that shuns condoms, about twelve thousand of the eighty-four million residents are infected with HIV. Jean-Marc Olive of the World Health Organization said that he’s not sure why this is, but he thinks they’re “lucky.” One gets the impression that “experts” would rather look puzzled than be forced to give credit to a chaste culture.
To appreciate the wisdom of the Filipino approach to halting the spread of HIV, contrast their efforts with the “safe sex” program implemented in Thailand. Both countries reported their first case of HIV in 1984. By 1987 there were 135 cases in the Philippines, and 112 in Thailand. The World Health Organization predicted that by 1999, 85,000 people would die of AIDS in the Philippines, and 70,000 in Thailand. In an effort to prevent this tragedy, Thailand enacted a “one hundred percent condom use program” and promoted widespread availability of condoms. Meanwhile, the Filipino government backed the Church’s plan to prevent the epidemic.
By 2005, Thailand’s HIV rate was fifty times as high as the Philippines (580,000 vs. 12,000). But because Thailand’s rate of new HIV infections is not as high as it used to be, it is hailed by “safe sex” experts as the model of how to protect a country against HIV. Health officials warn that an HIV epidemic has “the potential to explode” in the Philippines, but they are slow to acknowledge that if Filipinos hold fast to their morals, they’ll have nothing to fear. Compared to Western culture, Filipinos have a delayed sexual debut and a reduced number of partners. They are living proof that self-control always trumps birth control.
More Catholicism = Less AIDS
“The greater the percentage of Catholics in any country, the lower the level of HIV. If the Catholic Church is promoting a message about HIV in those countries, it seems to be working.”
While some people see the Catholic Church as an obstacle to HIV prevention, the British Medical Journal noted, “The greater the percentage of Catholics in any country, the lower the level of HIV. If the Catholic Church is promoting a message about HIV in those countries, it seems to be working. On the basis of data from the World Health Organization, in Swaziland, where 42.6 percent have HIV, only 5 percent of the population is Catholic. In Botswana, where 37 percent of the adult population is HIV infected, only 4 percent of the population is Catholic. In South Africa, 22 percent of the population is HIV infected, and only 6 percent is Catholic. In Uganda, with 43 percent of the population Catholic, the proportion of HIV infected adults is 4 percent.” In the Philippines, over 80 percent of the population is Catholic, and only .03 percent of the population has HIV!
The Catholic Church, like any good mother, wants what is best for her children. If your son or daughter had the chance to be sexually active with a person infected with HIV, what message would you give him or her? Would you entrust your child’s life to a piece of latex? Would you buy him or her a package of condoms, and then attempt to deliver a convincing abstinence message? Odds are, every loving parent would deliver an uncompromised message about abstinence. Why then would the Church do any less for her children?
Some argue that the Church’s opposition to condoms isn’t realistic because “some people are going to do it anyway.” But who are these “some people” who are incapable of being reached with the message of self-control? When I played college baseball, we were expected not to use steroids. Sure, some athletes do it anyway, but no coach would walk into the locker room and say, “We want you all to abstain from using performance-enhancing drugs. But since we know some of you will do it anyway, we’ll have a basket of free, clean syringes in the dugout.” Odds are, his players would not be inspired by his lack of confidence in them. If the coach truly cared about his players and wanted only the best for them, he’d motivate and empower them to make the best choice. In the same way, the Church will not give up on any human being but will continue to deliver the safest and healthiest message: chastity.
Critics may belittle the Catholic Church now, but as the saying goes, “All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self evident.”
All of these considerations should offer more than enough evidence that the Church’s stance on contraception does not stem from naïve traditionalism. It comes, in the words of one Vatican reporter, “from a profound analysis of the need to integrate sexuality in an exclusive and permanent relationship open to life in the context of marriage. The wisdom of this view is becoming increasingly clearer.” Critics may belittle the Catholic Church now, but as the saying goes, “All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self evident.”
To study the success of abstinence education and the failure of “safe sex” promotion in Africa, you may wish to read Evidence that Demands Action by the Medical Institute for Sexual Health, or Rethinking AIDS Prevention by Edward Green, a Harvard senior research scientist.
 Sue Ellin Browder, “Dirty Little Secret: Why Condoms Will Never Stop AIDS in Africa,” Crisis (June 1, 2006).
 Tim Allen and Suzette Heald, “HIV/AIDS Policy in Africa: What Has Worked in Uganda and What Has Failed in Botswana?,” Journal of International Development 16:8 (November 8, 2004), 1141–1154; Michael Cassell, et al., “Risk Compensation: The Achilles’ Heel of Innovations in HIV Prevention?” British Medical Journal 332 (March 11, 2006), 605–607.
 Craig Timberg, “Speeding HIV’s Deadly Spread,” Washington Post Foreign Service (March 2, 2007), A01.
 N. Hearst and S. Chen, “Condom Promotion for AIDS Prevention in the Developing World: Is It Working?” Studies in Family Planning 35:1 (March 2004), 39–47, emphasis added.
 Allen and Heald, 1141.
 Edward Green, et al., Evidence That Demands Action (Austin, Tex.: Medical Institute for Sexual Health, 2005), ii.
 Yoweri Museveni, 11th International Conference of People Living with HIV, as reported by Panafrican News Agency Daily Newswire (October 29, 2003).
 Joseph Loconte, “The White House Initiative to Combat AIDS: Learning from Uganda,” The Heritage Foundation: Backgrounder 1692 (September 29, 2003).
 Allen and Heald, 1141, emphasis added.
 Arthur Allen, “Sex Change: Uganda v. Condoms,” The New Republic (May 27, 2002).
 Allen and Heald, 1149.
 D. Low-Beer and R. Stoneburner, “Behavior and Communication Change in Reducing HIV: Is Uganda Unique?” African Journal of AIDS Research 2 (2004), 2.
 Edward Green, “Testimony before the Subcommittee on African Affairs,” Committee on Foreign Relations, U.S. Senate (May 19, 2003) 2.
 Edward Green, “The New AIDS Fight: A Plan as Simple as ABC,” The New York Times (March 1, 2003).
 Edward C. Green and Wilfred May, “Let Africans Decide How to Fight AIDS,” The Washington Post (November 29, 2003), A23.
 S. Gregson, et al., “HIV Decline Associated with Behavior Change in Eastern Zimbabwe,” Science 311:5761 (February 3, 2006), 620–621; Richard Hayes and Helen Weiss, “Understanding HIV Epidemic Trends in Africa,” Science 311:5761 (February 3, 2006), 620–621.
 Testimony of Edward C. Green, Ph.D., before the Committee on Energy and Commerce, U.S. House of Representatives (March 20, 2003), 3.
 Green and May, A23.
 Rand Stoneburner, quoted in Allen.
 Low-Beer R. Stoneburner, 1.
 AnnaWald et al., “Effect of Condoms on Reducing the Transmission of Herpes Simplex Virus Type 2 from Men to Women,” Journal of the American Medical Association285 (June 27, 2001), 3103.
 J. Thomas Fitch, “Are Condoms Effective in Reducing the Risk of Sexually Transmitted Disease?” The Annals of Pharmacotherapy 35:9 (September 2001), 1137; A. Saracco, et al., “Man-to-Woman Sexual Transmission of HIV: Longitudinal Study of 343 Steady Partners of Infected Men,” Journal of Acquired Immune Deficiency Syndromes6:5 (May 1993), 497–502; I. de Vincenzi, “A Longitudinal Study of Human Immunodeficiency Virus Transmission by Heterosexual Partners,” The New England Journal of Medicine 3331 (August 11, 1994), 341–346, as quoted in Fitch.
 S. Ahmed, et al., “HIV Incidence and Sexually Transmitted Disease Prevalence Associated with Condom Use: A Population Study in Rakai, Uganda,” AIDS 15:16 (November 9, 2001), 2171–2179.
 “New Research Confirms Condoms Not Effective in HIV Prevention,” LifeSiteNews.com (January 14, 2004).
 Joshua Mann, et al., “The Role of Disease-Specific Infectivity and Number Of Disease Exposures on Long-Term Effectiveness of the Latex Condom,” Sexually Transmitted Diseases 29:6 (June 2002), 344–349.
 R. E. Bunnell, et al., “High Prevalence and Incidence of Sexually Transmitted Diseases in Urban Adolescent Females Despite Moderate Risk Behaviors,” Journal of Infectious Diseases 180:65 (November 1999), 1624–1631.
 Fitch, 1137.
 “New Research Shows Dangers of Condoms in HIV Prevention,” Culture & Cosmos 1:23 (January 13, 2004), emphasis added.
 D.T. Fleming and J.N. Wasserheit, “From Epidemiological Synergy to Public Health Policy and Practice: The Contribution of Other Sexually Transmitted Diseases to Sexual Transmission of HIV Infection,” Sexually Transmitted Infections 75 (1999), 3–17.
 Peter Greenhead, et al., “Parameters of Human Immunodeficiency Virus Infection of Human Cervical Tissue and Inhibition by Vaginal Virucides,” Journal of Virology74:12 (June 2000), 5577–5586.
 Nancy Padian, et al., “Heterosexual Transmission of Human Immunodeficiency Virus (HIV) in Northern California: Results from a Ten-Year Study,” American Journal of Epidemiology 146:4 (August 15, 1997), 350–357.
 Dr. Daniel Low-Beer, as quoted by Alisa Colquhoun, “Ugandan Lessons?” Public Health News, February 6, 2004.
 Fitch, 1137; Ronald Gray, et al., “Probability of HIV-1 Transmission Per Coital Act in Monogamous, Heterosexual, HIV-1 Discordant Couples in Rakai, Uganda,” Lancet357 (2001), 1149–1153; I. de Vincenzi, “A Longitudinal Study of Human Immunodeficiency, 341–346; Medical Institute for Sexual Health, Sex, Condoms, and STDs: What We Now Know (Austin, Tex.: Medical Institute for Sexual Health, 2002), 13.
 Bluma Brenner, et al., “High Rates of Forward Transmission Events After Acute/Early HIV-1 Infection,” The Journal of Infectious Diseases 195 (April 1, 2007), 951–959; M. J. Wawer, et al., “Rates of HIV-1 Transmission Per Coital Act, by Stage of HIV-1 Infection, in Rakai, Uganda,” The Journal of Infectious Diseases 191:9 (May 1, 2005), 1403–1409.
 Harvey Elder, “Human Immunodeficiency Virus (HIV),” a presentation at Health on the Horizon, sponsored by The Medical Institute for Sexual Health (June 13, 2002).
 Seth Mydans, “Low Rate Of AIDS Virus In Philippines Is a Puzzle,” The New York Times (April 20, 2003).
 Human Life International, “Condom Exposé” www.hli.org, 16.
 UNAIDS “Report on the Global AIDS Epidemic,” 2006, Annex 2, 511, 514.
 Cecile Balgos, “Philippines Proud of its Low Infection Rate, Number of Cases,” San Francisco Chronicle (May 21, 2003).
 Amin Abboud, “Searching for Papal Scapegoats Is Pointless,” British Medical Journal 331 (July 30, 2005), 294.
 Bureau of Democracy, Human Rights, and Labor, “International Religious Freedom Report 2004,” U.S. Department of State (September 15, 2004); UNAIDS “Philippines” Country Situation Analysis (www.unaids.org).
 “Doubts About Condoms: Science Questioning Their Efficacy in Halting HIV/AIDS,” Zenit Daily Dispatch, Nairobi, Kenya (June 26, 2004).
 Commonly attributed to Arthur Schopenhauer.