Vatican City, Dec 13, 2015 / 04:02 am
On his return flight from Africa, as Pope Francis fielded the customary questions from the press, he challenged a journalist on a question about condom use in the fight to prevent HIV.
"We know that prevention is key. We know that condoms are not the only method of solving the epidemic, but it's an important part of the answer," the journalist said. "Is it not time for the Church to change its position on the matter? To allow the use of condoms to prevent more infections?"
The question, Pope Francis said, seemed too narrow to address such a widespread and complex issue. Condom use in and of itself could never solve the HIV crisis or other problems facing many African nations.
"The problem is bigger," the Pope said.
"This question makes me think of one they once asked Jesus: 'Tell me, teacher, is it lawful to heal on the Sabbath? Is it obligatory to heal?' This question, 'Is doing this lawful,'…but malnutrition, the development of the person, slave labor, the lack of drinking water, these are the problems."
The Catholic Church has always held that artificial contraception use is immoral. In a 2010 book interview that made waves, Pope Benedict XVI said that while using a condom can represent a step in the right direction as far as showing concern for the other person, it is still an immoral solution to the HIV crisis.
But was Pope Francis right to be so dismissive of condom usage? Do condoms actually play a practical and important role in the fight against HIV?
An increasing amount of evidence says no.
Abstinence and fidelity in Uganda
At the peak of the HIV crisis in the 1980s, the country of Uganda had one of the highest infection rates – almost 25 percent of the population were HIV positive by 1991, according to the Washington Post.
With the help of the country's religious leaders, Uganda President Yoweri Museveni adopted the simplest and least expensive intervention possible in the poor and war-torn country – a public education program stressing abstinence before marriage and faithfulness afterward, largely de-emphasizing condom use except for those most at risk.
In just eight years, the country saw the most significant decline in HIV infection rates in the world.
According to a 2004 article in 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."
But just as Uganda was seeing a significant decline, the United States intervened, restructuring the country's approach and focusing more on condoms and less on abstinence and monogamy. In an op-ed for the Washington Post, Harvard's leading HIV researcher Dr. Edward Green and Wilfred Mlay, then-vice president for World Vision Africa, wrote that while the United States was generous in offering their help, the Western ideologies and approaches may have actually undermined the success previously seen in Uganda.
"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. Health officials worry that infection rates may increase as well," they wrote.
The problem with condoms
Regardless of religious belief, condom use to curb HIV infection proves problematic for several reasons.
One of the biggest issues with the promotion of condoms as a solution to HIV is that most people do not consistently or correctly use condoms, even after going through sex education.
A study published by "The Annals of Pharmacotherapy" found that out of 500 couples who were repeatedly told by their doctors to use condoms, only eight percent did so consistently, despite knowledge that one partner had herpes. A different study found that only 50 percent of couples in which one partner had HIV used condoms consistently over time.
Another part of the problem is something called risk compensation. In an interview with the BBC, Dr. Green said that risk compensation happens when people use risk-reducing technology in a way that assumes the technology cancels out all risk.
As an example, in an interview with BBC, Dr. Green compared condom use to sunblock. He said the protection offered by sunblock is cancelled out when the person using sunblock assumes they are completely protected and therefore spends even more time in the sun.
Similarly, people using condoms are more likely to engage in risky sexual behavior because of the assumed protection, when in fact repeated exposure to infected persons decreases the protection that condoms offer.
The phenomenon of risk compensation also means people using condoms are more likely to have a greater number of sexual partners, increasing their risk for certain STDs which in turn increases the likelihood of the transmission of HIV. Many STDs create open sores, which act as portals of entry for HIV infection.
Another reason condoms alone fail at protecting people against HIV is because of the likelihood of disease transmission over time. According to a 2001 article in The Lancet, the more frequently one changes sexual partners, the more likely it is that they will spread HIV.
This is because HIV is highly contagious when it is first contracted, but it is often not detectable until later. Therefore, an infected person could think they are HIV-free and go on to infect more people before they realize they have HIV. The study found that if there were at least six months in between sexual partners, the rate of HIV infections would significantly decrease.
A tale of two countries: Philippines vs. Thailand
Two different countries in Asia help further illustrate the effectiveness of abstinence and fidelity programs over condom promotion.
In 1984, both countries reported their first case of HIV infection. But the two governments had radically different responses.
Thailand's response was to promote condom use across the board, while the largely Catholic country of the Philippines focused their response on promoting abstinence before marriage and fidelity afterwards.
By 2005, the HIV rate in Thailand was 50 times higher than that of the Philippines.
And while some experts hail Thailand as a success story rather than the Philippines, since Thailand's rate of infection eventually decreased from previous levels, other experts say it is no coincidence that the Catholicism which permeates Filipino culture has led to a small rate of HIV infection.
Catholicism and HIV infection rates
Although some experts are hesitant to recognize the effectiveness of abstinence and fidelity programs promoted by the Catholic Church, a 2005 article in British Medical Journal hailed their success.
"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," the article states.
"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."
Dr. Green, too, emphasized in a 2009 article that his support of abstinence and fidelity programs comes not from a conservative worldview but rather from his experiences in Africa and from looking at the results.
"I'm a flaming liberal, don't go to church, never voted for a Republican in my life," he said.
In his aforementioned op-ed, he also added that it would be a wrong to place politics and ideologies above the lives of people who are at risk.
"Billions of dollars and the lives of countless men, women, and children will be wasted if ideology trumps proven health policy."