AIDS Prevention Strategies in Africa
March 22, 2009 3:32 PM   Subscribe

According to Senior Harvard AIDS Prevention Researcher Dr. Edward Green, condoms not only are not helping to prevent the AIDS crisis, but are actually making the problem worse.
posted by Roach (47 comments total) 11 users marked this as a favorite

 
WOW, Hmm why would this come out "in a Catholic site" only After the Pope proclaim'd it? Hmm, Color me not convinced.
posted by Elim at 3:36 PM on March 22, 2009 [5 favorites]


So why would condom use work in Western countries but not Africa, then?
posted by dilettante at 3:38 PM on March 22, 2009 [2 favorites]


Only a matter of time before Kirk Cameron is back on the scene explaining this theory with a banana.
posted by Garak at 3:40 PM on March 22, 2009 [15 favorites]


the catholic news agency found an angle to spin this outrage in favor of the pope's position and you neglected to mention that? oookay.

this guys thesis seems to be that not using a condom correctly for lack of knowlege is worse than not using a condom at all. that is factually wrong. catching a cold twice because you don't know how to use a scarf is not worse than catching the cold four times because you didn't wear one at all and advocating people should adhere to "scripture and moral theology" is like saying they should stay indoors all winter long.

if a condom only saves only one person from catching hiv it's better, not worse. it's regrettable the rest thought they should chew on it.
posted by krautland at 3:42 PM on March 22, 2009


AskMeFi discussion.
posted by greta simone at 3:42 PM on March 22, 2009


Betchya his fave band is The Foo Fighters.
posted by Effigy2000 at 3:52 PM on March 22, 2009 [2 favorites]


Thanks for the link to the AskMefi discussion. Hadn't seen that.
posted by Roach at 3:53 PM on March 22, 2009


this guys thesis seems to be that not using a condom correctly for lack of knowlege is worse than not using a condom at all. that is factually wrong. catching a cold twice because you don't know how to use a scarf is not worse than catching the cold four times because you didn't wear one at all and advocating people should adhere to "scripture and moral theology" is like saying they should stay indoors all winter long.

Actually colds are caused by being cooped up indoors with lots of people, which is more common in the winter
An ancient myth still common today claims that a cold can be "caught" by prolonged exposure to cold weather such as rain or winter conditions.[14] Although common colds are seasonal, with more occurring during winter, experiments so far have failed to produce evidence that short-term exposure to cold weather or direct chilling increases susceptibility to infection, implying that the seasonal variation is instead due to a change in behaviors such as increased time spent indoors at close proximity to others.
So your suggestions about scarves and staying indoors are exactly backwards.
posted by delmoi at 3:56 PM on March 22, 2009 [4 favorites]


They're effective.. unless ur doin it wrong.
posted by chiraena at 4:05 PM on March 22, 2009 [4 favorites]


I don't think it's wise to dismiss outright that there are significant cultural differences between the West and Africa (if you can somehow group an entire continent of various cultures).

I've often wondered about the application of Western societal norms on the rest of the world. For example, I'm not convinced that sex anywhere/anytime/anyone is the BEST norm (for example). While I'm not advocating celibacy, or waiting until marriage, I do think that a strong argument can be made that we've allowed sex to devolve into a hobby, and we've failed to respect its very harmful effects (link). I think there's something to be said about having a healthy restraint. Just because you can, doesn't mean you should (same logic actually applies to rating agencies and investment banks in this current crisis, but I digress).

Studying sexual habits and their effects on STD transmission is such a difficult task. Some of these cultures are God fearing and have very conservative sexual values. Using those values to help save lives, while seemingly a bit Machiavellian, may not be such a bad idea. You gotta go with what works; our Malthusian/Darwinian approach of letting only those who perfectly understand the consequences of sex being allowed to survive is costing a lot of lives.
posted by SeizeTheDay at 4:07 PM on March 22, 2009


I found exactly one claim of fact in this article, with no supporting evidence given:
The accepted wisdom in the scientific community, explained Green, is that condoms lower the HIV infection rate, but after numerous studies, researchers have found the opposite to be true. “We just cannot find an association between more condom use and lower HIV reduction rates” in Africa.
True or false?
posted by DU at 4:16 PM on March 22, 2009 [3 favorites]


Some of these cultures are God fearing and have very conservative sexual values.

But often they don't practice these values, for all they declaim them, so using them to change behavior is futile. If their conservative sexual values aren't stopping them shagging then they aren't any use to you in preventing HIV transmission.
posted by alasdair at 4:19 PM on March 22, 2009 [2 favorites]


if a condom only saves only one person from catching hiv it's better, not worse. it's regrettable the rest thought they should chew on it.

I think the point is, while condoms prevent transmission among people who use them correctly ... there's a larger group of people who would never have otherwise have had sex that are now doing so because they know condoms are safer, and a subset of those people don't use condoms correctly, so transmission rates increase.

Imagine a set of 100 car drivers. Some of them are good drivers, while most are poor drivers. You give them all cars with airbags and then tell them these cars are safer than the ones they had before. Encouraged by the idea that the cars are safer, the poor drivers start going faster on the highways, overcoming any safety advantage the airbags offered the aggregate group.

On a practical level, you see this theory in other scenarios. For example, airlines don't require children to sit in "car seats" like they do on the roads. This is inherently less safe, for the same reason it is in cars.

But ... it lowers the overall cost for parents traveling with children. This is good for the airline. But, counter-intuitively, it's also good for the kids, because otherwise, the parents would be taking the kids on longer and longer car trips, which is far, far less safe than airline travel.

So, the math works. In theory.

Does it work here? Anyone who tells you they know is lying. But this is certainly a disprovable hypothesis. Let's run the numbers before we stop sending condoms to Africa.
posted by Cool Papa Bell at 4:23 PM on March 22, 2009 [3 favorites]


Dr. Green is not only supporting the Catholic viewpoint, but shilling his books. But behind that, there are some interesting ideas, such as risk compensation resulting in more sex, potentially with infected parters. I can't say how much merit his ideas have, being only an internet pundit and armchair activist, but let's see where this goes.
Claiming to be a liberal himself, Green asserts that promoting Western “liberal ideology” where, “most Africans are conservative when it comes to sexual behavior,” is quite offensive to them. Citing his new book, “Indigenous Theories and Contagious Disease,” Green described Africans as “very religious by global standards” who are offended by “trucks going around where people are dancing to ‘Rock ‘n’ Roll’, tossing out condoms to teenagers and the children of the village.”
There are a lot of religions in the world, and some of them have drastically different viewpoints on the world. Yet they hate rock & roll and free condoms as much as the Catholics? They're OK by in my book!
Green also noted that there is an ideology called “harm reduction” that is being pushed by many organizations trying to prevent AIDS. The ideology believes that “you can’t change the underlying behavior, that you can’t get people to be faithful, especially Africans,” the HIV specialist explained.
So you're saying that Africans, as a whole, are more likely to have risky sex anyway? Or that they are not faithful to a single partner? My, what a dire picture paint, and such a broad brush you use.
One country, Uganda, recognized these issues and said, “Listen, if you have multiple sex partners, you are going to get AIDS.” What worked in Uganda, a country that has seen a decline by as much as 2/3 in AIDS infections, was that officials realized that even aside from religious and cultural reasons, “no one likes condoms.” Instead of waiting for “American and European advisors to arrive,” Ugandan officials reacted and developed a program that fit their culture; their main message being “stick to one partner or love faithfully.”
But you just said that the underlying behavior for Africans is that they won't be faithful. So now you're offering fidelity as an alternative to practicing protected sex, AND you have some books to sell us? Consider yourself hired for the next MeetUp!
posted by filthy light thief at 4:25 PM on March 22, 2009


this guys thesis seems to be that not using a condom correctly for lack of knowlege is worse than not using a condom at all.

That's not his thesis. What he's observed is that risk-reduction measures can have the effect of increasing risky behaviour to the point that the original measure isn't just a wash, it's actually counter-productive. In comparison to AIDS in North America in the 80s, where it wasn't really possible to be more risky, the introduction of condoms dropped the infection rate.

In general, it's less an argument against condoms than it is against relying on widespread condom distribution alone to curb AIDS infection rates.
posted by fatbird at 4:26 PM on March 22, 2009


His explanation for the decline and recent rise in infections in Uganda is interesting and provocative, but the article doesn't offer any cites so I'll wait for the responses from AIDS prevention groups before I take his claims as fact.
posted by mediareport at 4:44 PM on March 22, 2009


To say that the Pope is right is ridiculous, since the Pope's statement and this guy's theory are not at all the same. The Pope is against condoms because they're contraceptives. Period. Had he been asked to elaborate on the idea that condoms make things worse, he wouldn't have said "well, I've been introduced to the admittedly counterintuitive findings of Professor Green...." He would have said openness to life, culture of death, etc. etc. If everytime you used a condom you added a year to your life, he'd still be against them. The Pope is against condom use in a marriage where one person is infected! And Professor Green is most certainly not against using condoms, and I think it's disgusting that he's piggybacking on the "news" of the Pope's statement to raise his profile and sell his books.
posted by moxiedoll at 4:51 PM on March 22, 2009 [6 favorites]


Quoted from his CV:

EDUCATION:

(1978-79) Vanderbilt University, Post-Doctoral Study, Mental Health Policy Analysis.
Ph.D. (1974) Catholic University of America (Anthropology)
M.A. (1968) Northwestern University (Anthropology)
B.A. (1967) George Washington University (Anthropology)
posted by Benjy at 5:06 PM on March 22, 2009 [7 favorites]


First of all, no one, but no one, is relying on condom distribution alone to reduce HIV transmission in Africa. Quite the opposite, in fact. As I linked in the green, here is a discussion of HIV in Uganda, including a piece on the "war on condoms."

Here's a media summary of why the pope is wrong about condoms and HIV transmission. Here's the UNAIDS and WHO statement on condoms.

Stephen Lewis's response: ""The Pope is living on the moon," said Stephen Lewis, who heads a foundation supporting groups that alleviate the deadly effects of HIV/AIDS.

And he added: "Every stitch of scientific evidence says condoms are the best preventive measure we have against the virus."

The Pope's remark was "another example of complete indifference to the vulnerability of women, who are so hugely and disproportionately affected by HIV/AIDS," Lewis said in an interview from Hamilton yesterday."
posted by gingerbeer at 5:11 PM on March 22, 2009 [3 favorites]


Green, Edward C., “Why We're Losing the War Against HIV/AIDS. Christianity Today
(Interview by Timothy C. Morgan). 03/07/2005.

Green, E.C. and John Berman, “Dangerous Liaisons Fueling AIDS in Africa.” Op-ed The
Washington Times
. Dec. 28, 2003
http://www.washtimes.com/functions/print.php?StoryID=20031226-114721-9697r

E.C. Green, “A (Roma/Gypsy) Community's Experience with a Faith-based
Organization.” CORE Initiative Discussion Forum Newsletter, Friday, January 24, 2003.

Green, E.C., “The Impact of Religious Organizations in Promoting HIV/AIDS
Prevention.” The CCIH Forum, Issue 11, Oct. 2001, pp. 2-11.
http://www.ccih.org/forum/0110-02.htm


Mosley. H., and E.C. Green “FBOs and HIV Prevention Strategies.” Faith and Global
Health Caucus Satellite Series.
Global Health Council Annual Meeting May 30, 2006.
Washington, DC.

Green, E.C. and Allison Herling, “The ABC Approach To HIV Prevention: Fresh
Evidence And Recent Controversies.” Annual Conference of Christian Connections in
International Health
. “Pathways to Health and Wholeness.” Buckeystown, Maryland, May
28, 2006.

Green, Edward C., Invited Plenary Session Keynote Address. “Lessons from Uganda.”
Lausanne Committee for World Evangelization, North American Consultation on the
Role of the Church in the HIV/AIDS Pandemic
. Louisville, Ky, 11/7/05.

Green, Edward C., “Has Uganda moved to Abstinence Only? “Christian Engagement in
Health Systems-- Where We've Been and Where We're Going. CCIH Conference, Shady
Grove, Maryland May 28-31, 2005.
http://www.ccih.org/conferences/presentations/index.htm


Green, E.C., “The Reasons HIV Prevalence Declined in Uganda.” Various versions
presented at, e.g. George Washington University School of Public Health, May 2003;
National Association of Evangelicals (“Evangelicals Respond to the Global AIDS
Crisis”)
, June 2003; The Medical Institute, Austin Texas, June 2003; Christian
Connections in International Health
, May 2003; Harvard University Sept. and May 2002;
etc .

Green, E.C., “The Contribution of Faith-Based Organizations to HIV/AIDS prevention:
Evidence from Uganda and Jamaica.” Paper presented at “Challenges for the Church:
AIDS, Malaria & TB” (Conference Title), Christian Connections for International Health
,
Arlington, Va., May 25-26, 2001. http://ccih.org/forum/0110-02.htm


There's a bunch more that I'm too lazy to copy. I suspect he might have an agenda, though.
posted by Benjy at 5:16 PM on March 22, 2009 [25 favorites]


Mediareport, he is a director at an AIDS prevention group.
posted by Houstonian at 5:16 PM on March 22, 2009


Fair point, Houstonian, didn't mean to imply otherwise. I'm not dismissing him, either, because his claims appear to get more of a hearing in religious and conservative outlets.

I am waiting for pointers to rebuttals of his claim about Uganda before jumping to any conclusions.
posted by mediareport at 5:21 PM on March 22, 2009


But you just said that the underlying behavior for Africans is that they won't be faithful.

Actually, he said "that there is an ideology called 'harm reduction' that is being pushed by many organizations trying to prevent AIDS... [that] believes that 'you can’t change the underlying behavior, that you can’t get people to be faithful, especially Africans'.” He did not endorse that view.

I am not sold on the views that he does endorse, but it's not helpful to distort them.
posted by Kirth Gerson at 5:32 PM on March 22, 2009


I mention this in the AskMefi page, but if you are interested in some of the statistics and studies he used, you can view this presentation he gave.

Of particular note, I think, is the last bullet point on Slide 28, "So What Was Different in Uganda?" The last bullet point says, "ABC approach (not to be confused with
Bush & religious conservatives)".
posted by Houstonian at 5:39 PM on March 22, 2009


It is also not helpful that he is wildly distorting what harm reduction is. Harm reduction absolutely believes that individuals can change their behavior. That is a core component of what harm reduction IS.
posted by gingerbeer at 5:41 PM on March 22, 2009


The CNA can go to hell.

Damned schismatics.
posted by koeselitz at 5:45 PM on March 22, 2009


My take is that you can find an article or researcher promoting just about every viewpoint, assertion doesn't equal truth, ever.
posted by IvoShandor at 5:54 PM on March 22, 2009


Seems to me that what is being said is that I will have sex because I have been told that condoms prevent sex. Then I don't use the rubber properly and voila! I get AIDS...then why not say condoms and everything else doesn't work so just try chastity since you are in a conservative society. We are led to believe that those who would not have sex for fear of the disease do have sex because they think the condom protects. Ok. Just say no.
posted by Postroad at 6:11 PM on March 22, 2009


I would put more weight in his claim if he was a career epidemiologist with research to back up his claims, and not an anthropologist with a fundamentalist religious agenda.
posted by Blazecock Pileon at 6:38 PM on March 22, 2009


So how many T-cells, exactly, can dance on the head of a pin? People are (literally) dying to know.
posted by joe lisboa at 6:55 PM on March 22, 2009


According to Green, the Catholic Church should continue to “do what it is already doing,” avoid “arguing about the diameter of viruses” and cite scientific evidence in connection with scripture and moral theology.

Yeah, good luck with all of that.
posted by blucevalo at 7:09 PM on March 22, 2009


Actually, this guy signed onto this, which says that condoms are an essential part of AIDS prevention-- although maybe he's changed his mind and become anti- condom later.

But he's completely and utterly wrong about the data on condoms and on the other harm reduction measure that has made a huge difference in AIDS: needle exchange. I'm way more familiar with the needle exchange data, so I'll start there.

People argued for years that you would increase injecting by handing out clean needles and that fewer people would get into drug treatment if needles were made available legally. In fact, recovering people and non addicts were going to rush out and start shooting up, because previously, the laws that made needles illegal were the only thing that stopped them from being IVDU's, given how attractive the junkie lifestyle is. I mean, isn't that the only reason you aren't shooting up right now?

If the needles-promote-more-use argument were true, syringe distribution should have been even more dangerous than condom handouts because clean needles-- unlike condoms-- make the activity in question *more* pleasurable. Why? A clean needle is more likely to properly hit a vein, being new-- and if you hit in the vein, you get a better shot, without all that digging around you have to do with less sharp, used needles.

Guess what? The anti-needle exchange people were completely, 100% wrong. Hundreds of studies found that not only did providing clean needles not increase injecting, needle exchanges actually turned out to be a good way of attracting addicts into treatment to come off drugs. No scientific body that ever looked at it-- CDC, NIH, WHO, ACMD, every single one-- ever found against needle exchange. It is one of the best supported interventions in all of public health.

Let me just pose the question this way: do you get hot when you see a condom? Does just the idea of a condom make you want to rush out and have sex? If someone on the street handed you a condom, would you go out and find someone to fuck that you hadn't otherwise planned on sleeping with? I didn't think so. And while there are plenty of cultural differences between Africa and the Western world, I do not think this is one of them.
posted by Maias at 7:25 PM on March 22, 2009 [28 favorites]


So let me get this straight. The distribution of condoms in Africa as an effective defense against HIV infection makes other people complacent about the risks and for that reason should not be condoned?

I think the lesson here is just how pernicious ideological indoctrination can be on persons (Dr. Green) who otherwise display a potential for deep intelligence.
posted by gallois at 7:53 PM on March 22, 2009


Btw, the idea that people have a "risk thermostat" and therefore will drive faster if you give them seatbelts and death rates won't go down doesn't mean that seatbelts increase death rates. They still reduce them. The decline just isn't as steep as predicted-- that's why the hypothesis developed-- and it is believed to be because of this kind risk compensation.

That's very different from seatbelts and airbags making cars *less safe*-- and I don't think anyone has ever shown any degree of risk compensation in sexual behavior, which makes the argument even more irrelevant.
posted by Maias at 7:58 PM on March 22, 2009


I suspect he might have an agenda, though.

I think the lesson here is just how pernicious ideological indoctrination can be...


etc.

None of that on display here for sure.
posted by txvtchick at 9:04 PM on March 22, 2009 [2 favorites]


"If someone on the street handed you a condom, would you go out and find someone to fuck that you hadn't otherwise planned on sleeping with?"

Why would you have to go out to find someone to fuck if someone just handed you a condom on the street?
...just sayin'

Look, clearly we should rethink our use of condoms until we can prove conclusively with scientific evidence whether the Pope is beyond doubt living on the moon or not. I mean that would point to the Vatican having some pretty advanced technology.
posted by Smedleyman at 9:22 PM on March 22, 2009


That's very different from seatbelts and airbags making cars *less safe*-- and I don't think anyone has ever shown any degree of risk compensation in sexual behavior, which makes the argument even more irrelevant.
posted by Maias at 8:58 PM on March 22 [+] [!]


What about Volvo drivers? (can't find the cite right now, unfortunately) engaging in riskier behavior because they see themselves as protected?
posted by mecran01 at 9:38 PM on March 22, 2009


One country, Uganda, recognized these issues and said, “Listen, if you have multiple sex partners, you are going to get AIDS.” What worked in Uganda, a country that has seen a decline by as much as 2/3 in AIDS infections, was that officials realized that even aside from religious and cultural reasons, “no one likes condoms.” Instead of waiting for “American and European advisors to arrive,” Ugandan officials reacted and developed a program that fit their culture; their main message being “stick to one partner or love faithfully.”
He's pretty much completely wrong on that, at least according to this article.
Research from the heavily studied Rakai district in southern Uganda suggests that increased condom use, coupled with premature death among those infected more than a decade ago with the AIDS virus, are primarily responsible for the steady decline in HIV infections in that area.
posted by afu at 11:32 PM on March 22, 2009 [2 favorites]


If I get this straight, he's arguing that since people in Africa are so poorly educated on matters of STI transmission and proper condom use, that giving them condoms and telling them condoms mean safer sex is causing them to have more unprotected sex?

Wouldn't the answer to this be more education, not fewer condoms?
posted by tehloki at 1:25 AM on March 23, 2009 [1 favorite]


Seems to me that what is being said is that I will have sex because I have been told that condoms prevent sex.

Well, um, ah ...
posted by Kirth Gerson at 3:26 AM on March 23, 2009


mecran0, re: the Volvo drivers, what that does is make Volvos less safe than they "should" be because of the protection devices in them-- it doesn't make them more dangerous than other cars. In other words, you can drive more miles before having an accident, but the number of accident deaths doesn't go down by as much as the safety devices safety enhancement predicts they should.

Sports cars still have way more crashes than Volvos-- but Volvos don't have as many fewer accidents as you'd predict.

Where this *does* become an issue is with helmets and bicycles. Apparently, cars drive closer to helmeted bike riders, thinking they are safer, and that according to a study I read recently, may completely wipe out the safety benefit from the helmet on a population level.

Nonetheless, is a helmeted biker safer in a collision with a car than an unhelmeted one? indeed, by a great deal.
posted by Maias at 5:47 AM on March 23, 2009


The push for abstinence until marriage, and the so-called "zero-grazing" policy discouraging sex with multiple partners, does not appear in the Rakai study to have made an impact, according to Gray.

"Over the past decade, we're just not seeing it," he said.


Thanks for that link, afu. That's pretty much the opposite of what Green is claiming happened in Uganda.
posted by mediareport at 5:57 AM on March 23, 2009


Where this *does* become an issue is with helmets and bicycles. Apparently, cars drive closer to helmeted bike riders, thinking they are safer, and that according to a study I read recently, may completely wipe out the safety benefit from the helmet on a population level.

I would love to see a cite on this. Not because I want to argue about it; that's a fascinating statistic if it's true, and I'd love to read the study.
posted by davejay at 7:46 AM on March 23, 2009


davejay:

http://www.bhsi.org/walkerstudy.htm
posted by spacediver at 9:11 AM on March 23, 2009


sorry:

hyperlinked:


posted by spacediver at 9:11 AM on March 23, 2009


erm:

here
posted by spacediver at 9:12 AM on March 23, 2009


Technologies intended to reduce harm can in fact backfire in some cases. But this guy has in no way made the case for this being true of condoms and HIV infection, not in Africa and not anywhere. He is not an epidemiologist and, in fact, he has not practiced epidemiology at all. He's more of a policy analyst and definitely has an ax to grind. Why, I can hear the whining sound now...
posted by Mental Wimp at 3:55 PM on March 23, 2009


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