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AFRICA/ Green (Harvard): as a liberal, I say the Pope is right

March Mon 23, 2009

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Dr. Edward Green is Director of the AIDS Prevention Research Project at the Harvard School of Public Health and Center for Population and Development Studies. He is a medical anthropologist with 30 years of experience in developing countries and in the fight against AIDS. Ilsussidiario.net has interviewed Dr. Green on the Pope’ statement about AIDS.

 

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.

Apart from the Uganda case, there are other evidences that the so-called ABC model could work?

We are seeing HIV decline in at least 8 or 9 countries in Africa. In every case, the proportion of men and women reporting multiple sexual partners has decreased a few years before we see the decline. Yet most AIDS programs emphasize condoms, testing, and drugs. So this broad behaviour change has come about in spite of national AIDS programs that have put the emphasis in the wrong places (for Africa). I’m happy to report that the two countries with the highest infection rates, Swaziland and Botswana, have both launched campaigns aimed at discouraging multiple and concurrent sexual partners.

Abstinence among teenagers is also a factor, obviously. If people begin to have sex at a later age, they end up having fewer numbers of sex partners during their lifetime, and this decreases chances of HIV infection.

So, in the struggle against AIDS the reduction in multiple and concurrent sexual partners is the most important factor.

 That is indeed the most important challenge, as I’ve already said.

 

A last question. In the model ABC, A and B are economically not so relevant as C, with a strong industry behind. Is it undue to say that it is not only a cultural and medical issue, but an economic one as well?

 I’m not sure by what you mean by economics here. If we think about ABC programs, PEPFAR is the only major donor that has put real funding into A or B, and perhaps unfortunately most of the money-- or at least emphasis-- has been for/on abstinence. The B factor is the most important one, with abstinence second, in my opinion, and according to the evidence I have seen.

If you mean by economics, whether poverty drives AIDS, then here again Africa is different from the rest of the world. In Africa, you see higher infection rates among people who are wealthier and better educated. So improving African economies will not bring down HIV rates. (But this is not a good reason to ignore struggling African economies.)



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