Tuesday, March 17, 2009

You may be anti-contraception, but let's not blatantly lie

by Amelia Thomson-DeVeaux

There's been a lot of dialogue on this blog over the past couple of weeks about the Catholic Church, what with controversy over washing machines, the seven deadly sins, and abortion, but I'm a little bit flabbergasted by this latest from the head of the Catholic Church. Pope Benedict XVI, on his way to Africa yesterday, repeated the Church's position on condoms and the spread of AIDS - that they don't help. This isn't a surprise (this position was articulated often and clearly by Pope Benedict's predecessor, Pope John Paul II, who said that abstinence, not contraceptives like condoms, were the solution to the problem of AIDS), but the pope's next sentence is certainly shocking. ""You can't resolve [AIDS] with the distribution of condoms," the pope told reporters aboard his plane headed to Africa. "On the contrary, it increases the problem."

According to Pope Benedict, the Catholic Church is at the forefront of the fight against AIDS - but we need a "responsible and moral" outlook to fight it. Rebecca Hodes, of the Treatment Action Center in South Africa, has a bit of a different spin. She said that if the pope is serious about saving the lives of the 22 million people infected with HIV in sub-Saharan Africa, he will focus on contraceptive education and distribution of condoms. "Instead, his opposition to condoms conveys that religious dogma is more important to him than the lives of Africans," said Hodes.

I understand the Church's opposition to contraceptives, even if I don't agree with it. And certainly, they have the right to spend their money as they see fit - if Pope Benedict wants to funnel the Church's millions into a "responsible and moral" cure for AIDS (which I'm suspecting has something to do with abstinence...just a wild guess), that's his prerogative. But it is completely inappropriate for him to suggest that condoms are not an effective method for preventing AIDS, and absolutely untrue that they exacerbate the problem.

Safe sex activists admit that condoms are not 100% effective, but according to the United States Center for Disease Control, studies examining sexually active people at high risk for contracting HIV have found that "even with repeated sexual contact, 98-100% of those people who used latex condoms correctly and consistently did not become infected." If condoms aren't working, it's because people aren't been taught how to use them correctly, or because the condoms have been stored in bad conditions for too long. The United Nations Joint Programme on HIV/AIDS says that "the male latex condom is the most efficient and available technology to reduce the sexual transmission of HIV" (emphasis mine). That sounds pretty certain to me.

The pope is one of the most influential people in the world. And although I can't take issue with the fact that he articulates beliefs that I don't agree with, it is absolutely wrong for him to make statements which he is incapable of backing up. Africa is the fastest-growing region for the Roman Catholic Church, and when the pope says something like this, it's not just a question of dogma. It's about people's lives.

13 Comments:

At March 18, 2009 at 11:19 AM , Blogger TommyD said...

As a non-theistic Heritage Catholic, I'm flabbergasted that anyone still listens to anything the Pope says. I can only hope that this latest outrage (condoms make the AIDS crisis worse!), coupled with his recent embrace of Nazi priests make people realize just how ludicrous the Papacy is. (And they wonder why they can't find any new priests.)

 
At March 18, 2009 at 12:52 PM , Anonymous Dan said...

Amelia,

I really don't relish the role of Defender of the Church, but here goes anyway...

First of all, I hope nobody considers the statement "You can't resolve [AIDS] with the distribution of condoms" to be controversial. Even if the distribution of condoms is a reasonable measure to take, it has to be considered a temporary, stopgap measure. Also, who can doubt the assertion that the teachings of the church, if they were actually followed by everyone, would stop AIDS dead in its tracks?

The only possibly controversial statement the pope made was the further assertion that "On the contrary, it increases the problem." This requires further explanation. Perhaps he did explain, but it wasn't reported. I don't know.

However, your own statement "But it is completely inappropriate for him to suggest that condoms are not an effective method for preventing AIDS, and absolutely untrue that they exacerbate the problem." is equally dogmatic.

Let's look at the first part of your statement. There is a huge difference between 100% and 98% effectiveness when it comes to preventing the transmission of AIDS. This is because the probability of becoming infected is cumulative, so even a 2% failure rate translates into virtual certainty of infection over time. Condoms *are* better than nothing, but only if you were going to have sex anyway, and only in the sense that their effect, on average, is to delay infection. So, no, I really don't consider condoms to be an effective method for preventing AIDS, and I wouldn't bet my life on them, so why would I ask someone else to do that?

And now for the second part of your statement "...absolutely untrue that they exacerbate the problem." I wouldn't be so sure. If the distribution of condoms results in a false sense of security, it could lead to an increase in the number of uninfected people having sex with someone who is HIV positive, and this could be enough to overwhelm the small (cumulative) benefit that condoms provide.

Some people have raised the issue of a woman who is married to an HIV positive man (a common occurrence in Africa), and is not able to refuse having sex with him. Shouldn't we provide condoms for her? Maybe. But only as a stopgap measure. With or without condoms, she is going to become infected with HIV eventually if she keeps having sex with an HIV positive man. The real solution is to empower her to say no to sex, or to get out of the relationship, or to avoid getting married to someone who is HIV positive in the first place (apparently many of these men are already HIV positive when they get married).

 
At March 18, 2009 at 8:27 PM , Blogger Franki said...

Being raised in the Church, the statements released by the Vatican on the subject of AIDS/pregnancy/STDs have been some of the most difficult things for me to come to terms with. It baffles me that an institution so concerned with the souls of it's followers has so little concern for their lives. The Catholic Church's position on AIDS is irresponsible at best and homicidal at its absolute worst. Unfortunately, it seems that Benedict XVI will be well into his dotage before he seeks a more reasonable policy. There are a lot of good things one can say about consistent guidelines, but not when those guidelines are so completely in conflict with the world at large. The Church is having a philosophical discussion when it needs to operate on a more practical level. Philosophy is fine when you're not dealing with real people; humanity tends to make things a bit more muddy.

tl;dr conclusion: More Catholics need to publicly doubt papal infallibility. It's all well and good for Benny to spout bullshit, but if he's going to do that then we need people on the ground counteracting his shenanigans.

 
At March 19, 2009 at 6:53 AM , Blogger TommyD said...

Dan,
As someone who works to to combat the spread of HIV in Africa, I'm going to have to set the record straight on a number of your claims. You write that "even a 2% failure rate translates into virtual certainty of infection over time," and that a woman having sex with her HIV-positive husband "is going to become infected eventually," with or without condoms. This is simply not true.

In unprotected penile-vaginal intercourse, a woman's risk of contracting HIV from an infected man is 10:10,000, and a man's risk of contracting HIV from an infected woman is 5:10,000. This does not mean that a woman has to have sex 1000 times with HIV-positive partners to contract HIV. Rather, it means that for every 10,000 "couplings" that occur between infected men and uninfected women, we expect that 10 women will contract HIV.

Now, if condoms are 98% effective against HIV, the rate drops from 10:10,000 to 0.2:10,000, so for every 10,000 couplings, only 0.2 women are expected to be infected. Put another way, there are now 9.8 women who would have been infected who now are not. You may not consider this to be particularly meaningful, but people who work in public health and epidemiology certainly do.

Promoting sexual fidelity is an important component of the fight against HIV, but so are condoms. Promoting abstinence has been effective with certain populations in Africa (e.g., children who have not yet had sex) but not with others (e.g., commercial sex workers, married people). Denying condoms to these people is like denying life jackets to boaters, because, you know, the only 100% effective way to avoid drowning is to stay on land.

Condoms do not merely "delay infection" but prevent hundreds of thousands of "would-be" infections every year. Your assertions betray a shocking amount of ignorance of the situation, matched only by the arrogance of your certainty. In this respect, sir, you are very much like the Pope.
Regards,
Thomas

 
At March 19, 2009 at 5:58 PM , Anonymous Dan said...

Thomas,

I think you're misinterpreting the meaning of the 98% figure. But before I address that, would you please provide a reference for your stated ratios (ie. the 10:10,000 and 5:10,000).

Thank you.

 
At March 20, 2009 at 5:16 AM , Blogger TommyD said...

Figures are from a CDC study, which you can download here:
http://www.ncbi.nlm.nih.gov/pubmed/11773877

 
At March 20, 2009 at 10:25 AM , Blogger LSG said...

I don't mean to interrupt the statistical conversation, but I do want to make a somewhat unrelated point.

Given that we are talking about the pope here, it's not unnatural that the issue of distributing condoms/distributing misinformation about condoms gets framed as a Catholic/non-Catholic dispute. I find the pope's position reprehensible and think it should be vigorously opposed on every front, but we have to be sure not to let his silly remarks make us believe this is a Catholic/non-Catholic issue only.

On a positive note, there are several Catholic bishops who support the distribution and use of condoms, seeing condom use for the purpose fo preventing HIV infection as part of a Catholic's right and duty to preserve life. This link quotes and provides citations to some of their public statements: http://www.catholicsforchoice.org/topics/hivaids/bishopssupportcondoms.as
I'm particularly impressed with South African bishop Kevin Dowley, who specifically cites the needs of women (a few of the bishops make statements to the effect of "I guess condoms should be used during marital rape." ARGH). Obviously, these men don't speak for all Catholics, but I find their positions extremely heartening. Not all Catholics, even high-ranking Catholic clergymen, agree with Benedict XVI on this one.

(Incidentally, my understanding of papal infallibility is that it doesn't apply to any old statement he throw out, but only to specific declarations or decrees -- help me out, Catholics?)

On a negative note, systematically spreading misinformation about condom usage and HIV infection is not in any way limited to Catholicism. Abstinence-only "educators" and many conservative Protestant groups happily promote lies about condoms all day long. For instance, in Focus on the Family's James Dobson's book Preparing for Adolescence he solemnly declares that latex condoms are basically a "net" that catches some sperm but that the HIV virus flows through easily. I've heard this repeated, with some variation, by numerous evangelical Christian leaders (local and national) and even by one of my own high school sex education teachers. And of course, we're all familiar with the abstinence-only education advocates' "condoms encourage sex" refrain.

I think we need to see this as an opportunity to disseminate correct information about HIV and condoms, and be sure not to get bogged down in a "do we or do we not like the pope" conversation -- that conversation hasn't really taken off here, but it's raging on some other blogs and it seems deeply unproductive. Pope's comments are wrong and morally dubious at best, yes, now let's use this publicity storm to make sure everybody hears clearly articulated arguments about the benefits of and need for condoms in the fight against HIV/AIDS.

 
At March 21, 2009 at 10:34 PM , Anonymous Dan said...

Thomas,

First of all, please understand that I do not intend what follows as a personal attack on you or the work that you are doing in Africa. I am merely attempting to challenge some prevailing assumptions, some of which are evidently so entrenched that many people here are quick to denounce the holder of an opposing view without even considering the possibility that a different perspective might have some validity.

In my first comment, I attempted to illustrate the point just using the figure that Amelia quoted in her piece. Now I will present a quantitative analysis using the best data I could find during the few hours that I was able to devote to this. Obviously, this is going to be indicative rather than definitive. I'll place references to the original sources in a separate follow-up comment.

Regarding the HIV transmission rate for unprotected sex, I quote from the summary of Ref. 1:

"Studies of cumulative HIV incidence suggest that cofactors such as genital ulcer disease, HIV disease stage, and male circumcision influence HIV transmission; however, the heterosexual infectivity of HIV-1 is commonly cited as a fixed value (approximately 0.001, or one transmission per 1000 contacts). We sought to estimate transmission cofactor effects on the heterosexual infectivity of HIV-1 and to quantify the extent to which study methods have affected infectivity estimates... A single value for the heterosexual infectivity of HIV-1 fails to reflect the variation associated with important cofactors. The commonly cited value of 0.001 was estimated among stable couples with low prevalences of high-risk cofactors, and represents a lower bound. Cofactor effects are important to include in epidemic models, policy considerations, and prevention messages."

In what follows, I will assume a transmission rate of 0.001 per contact, but we should keep in mind that the actual value in real situations may be higher. I note in particular that "persons who are in the process of seroconverting may be much more infectious than asymptomatic infected persons" (Ref. 2).

Regarding the effectiveness of condoms at preventing HIV transmission for heterosexuals, Ref. 3 concludes that "Overall effectiveness, the proportionate reduction in HIV seroconversion with condom use, is approximately 80%." I will assume an effectiveness of 80% in what follows.

Effectiveness in this context can be interpreted as a per contact reduction in transmission probability. In practice, it is measured by looking at the cumulative transmission probability over a moderate period of time (typically one year) for a group of serodiscordant couples (ie. one member of the couple has HIV and other does not, at the beginning of the study).

Thus, I will take the transmission rate per contact with condom use to be 0.001 x 0.2 = 0.0002. The corresponding probability of remaining uninfected is 1 - 0.0002 = 0.9998. After 2 contacts, the cumulative probability would be 0.9998 x 0.9998, and after 3 contacts it would be 0.9998 x 0.9998 x 0.9998 or (0.9998)^3, and so on. For example, after 100 contacts, the cumulative probability is (0.9998)^100 = 0.9802. I believe the 98% figure in Amelia's piece came from this type of analysis, but I was not able to find any reference to it on the CDC web page.

If I pick a typical serodiscordant couple, I can ask what is the probability that they are still serodiscordant after one year. The answer will of course depend on how many times they have sex during the year. If I assume once per day on average, the corresponding cumulative probability is (0.9998)^365 = 0.93, which means there is a 7% probability that the previously uninfected person becomes infected during one year.

Without condoms, this probability would be (0.999)^365 = 0.69, meaning there would be a 31% probability that the previously uninfected person becomes infected after one year. For a group of 100 serodiscordant couples, one would expect roughly 31 new infections in the year without condoms, vs. 7 new infections with condoms. Thus, over the course of the year, condom availability would save 24 people. This is the argument for using condoms. However, there are two important objections that one could make:

1. There are still 7 new infections. Had these people avoided sexual contact with an HIV positive partner, instead of relying on condoms, they would still be healthy.

2. The outlook for the remaining 93 people (which of course includes the 24 who were saved from infection during the first year) is not good if they continue having sex with an HIV infected partner, even with condoms. This becomes clear if you work out the cumulative probability of remaining uninfected over, say, 10 years, and longer, say 30 years.

After 10 years, the cumulative probability is (0.93)^10 = 0.48 and after 30 years it is (0.93)^30 = 0.11.

You can change some of my starting assumptions and get different probabilities, but it is virtually impossible (as far as I can tell) to obtain good odds over the long term. This is the basis for my claim that condoms should at best be considered a stopgap solution.

In addition to condom effectiveness, there is also the issue of inconsistent use. Here I draw your attention to a recent article published in Science (Ref. 4). Quoting from the article:

"Condom promotion is effective in epidemics spread mainly through sex work, as in Thailand and also, to some extent, among other high-risk groups such as MSM. Although condom use has also likely contributed to HIV decline in some generalized epidemics, there is no evidence of a primary role. This is because consistent condom use has not reached a sufficiently high level, even after many years of widespread and often aggressive promotion, to produce a measurable slowing of new infections in the generalized epidemics of Sub-Saharan Africa. When most transmission occurs within more regular and, typically, concurrent partnerships, consistent condom use is exceedingly difficult to maintain."

The most shocking thing about this statement is that, within the general population (ie. excluding certain high risk groups) condom use has not even slowed down the rate of new infections to any measurable degree.

The authors conclude from their analysis that the two measures that actually work are male circumcision and reducing multiple sexual partnerships.

What about the claim that condoms make things worse? It turns out that there is published research supporting this view as well.

Ref. 5 states: "It is argued that the promotion of condoms at an early stage proved to be counter-productive in Botswana, whereas the lack of condom promotion during the 1980s and early 1990s contributed to the relative success of behaviour change strategies in Uganda."

Ref. 6 suggests a reason for this:
"In aggregate, our data do not support a net reduction in HIV risk through a program focused on condom promotion in this setting. The increase in condom uptake that the intervention produced seems not to have been sufficient to counteract the increase in numbers of sex partners. Although this was not the result we intended or expected, it is consistent with the history of AIDS prevention efforts in Uganda."

What to conclude from all of this? I don't know. Maybe just that it is reasonable to question the prevailing views regarding the benefits of condom distribution, and we ought not to react so harshly toward anyone who does.

 
At March 21, 2009 at 10:38 PM , Anonymous Dan said...

References for my previous comment

1. Rethinking the heterosexual infectivity of HIV-1: a systematic review and meta-analysis
Kimberly A Powers MSPH, Charles Poole ScD, Audrey E Pettifor PhD, Prof Myron S Cohen MD
The Lancet Infectious Diseases, Volume 8, Issue 9, Pages 553 - 563, September 2008
doi:10.1016/S1473-3099(08)70156-7

2. http://www.ncbi.nlm.nih.gov/pubmed/9663408

3. Condom effectiveness in reducing heterosexual HIV transmission
Weller SC, Davis-Beaty K.
Cochrane Database of Systematic Reviews 2002, Issue 1. Art. No.: CD003255. DOI: 10.1002/14651858.CD003255.
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003255/frame.html

4. Reassessing HIV Prevention
Malcolm Potts, Daniel T. Halperin, Douglas Kirby, Ann Swidler, Elliot Marseille, Jeffrey D. Klausner, Norman Hearst, Richard G. Wamai, James G. Kahn, Julia Walsh
Science 9 May 2008: Vol. 320. no. 5877, pp. 749 - 750
http://www.sciencemag.org/cgi/content/full/320/5877/749

5. HIV/AIDS POLICY IN AFRICA: WHAT HAS WORKED IN UGANDA AND WHAT HAS FAILED IN BOTSWANA?
TIM ALLEN and SUZETTE HEALD
J. Int. Dev. 16, 1141–1154 (2004)
http://www3.interscience.wiley.com/cgi-bin/fulltext/109751930/PDFSTART

6. Increasing Condom Use Without Reducing HIV Risk: Results of a Controlled Community Trial in Uganda.
Phoebe Kajubi; Moses R Kamya, MD; Sarah Kamya; Sanny Chen, MHS; Willi McFarland, MD; Norman Hearst, MD, MPH
JAIDS 40:77-82, 2005

 
At March 22, 2009 at 10:01 PM , Anonymous Corita said...

Franki,
What does it mean to say that the Church "needs to operate on a more practical level"?
Do you mean that the Church should operate soup kitchens, work programs, shelters, hospitals, immigrant outreach programs, ministries to the sick and dying, prison ministries, visit the homebound, clothing drives,speak out against injustice and oppression, support the role of science in public life, oppose war and the death penalty, put on worship services, train and care for religious brothers & sisters and priests, run schools, newspapers, printing presses, television stations, travel the world making peace and improving relations with other religions, encourage peace and responsibilty to one another, anoint the sick and bury the dead?

I agree that the Church must do this. Hey! It already does.

Should the Pope say, "Fuck all this philosophy about a totality of being in which all elements of existence are seeking to order themselves to the same end; if I tell people to use condoms then they will (because they were listening to me before, when I told them to be monogamous and abstain before marriage)... and using condoms will save all of them (even the non-CAtholics who will also listen to me)....and thus AIDS will be squashed by my very practical message!! And those thousands of years of thinking about how to be a person of integrity won't matter at all if I kill AIDS!"

Is that what you mean by getting more practical and less philosophical?

(Sorry to be silly and snarky, butI am kind of tired of the denigration of philosophy and the exaltation of utilitarianism; it really turns us all into meat for production and consumption.)


LSG:
You are correct; papal infallability refers only to very specific kinds of teachings on very specific kinds of ideas, and is rarely invoked. I think that lots of people misunderstand it, though, including those who were "raised int he Church," which I learned as a teacher in a Catholic high school was far from a guarantee that you had gotten any kind of good understanding of what Catholicism actually is.

 
At March 22, 2009 at 10:04 PM , Anonymous Corita said...

Also, wanted to note that I (granted, not able to comprehend statistics very well) have been reading plenty of AIDS researchers and activists who agree that "just giving out condoms" doesn't work, and in fact can encourage things like more risky behavior based on a "penumbra of safety" (I am probably getting the terms messed up; too tired.....)

So why is it believed to be a lie? Just because the Pope says it? Or doesn't it really depend on how you examine the problem?

 
At March 24, 2009 at 11:15 AM , Anonymous Emily said...

"The authors conclude from their analysis that the two measures that actually work are male circumcision and reducing multiple sexual partnerships.”

Is this at all realistic? In cultures where males dominate, and even in those few where they do not, male circumcision seems entirely ludicrous. Of course if a person can’t have sex, then it becomes harder to contract HIV/AIDS. The second clause is another obvious way to prevent the spread of the disease, but it is hard to change people’s minds when they aren’t properly educated and they do not necessarily believe in fidelity.

“There are still 7 new infections. Had these people avoided sexual contact with an HIV positive partner, instead of relying on condoms, they would still be healthy.”

It is very hard to expect people who have led a life with sex to just give it up all together, and for people to not start a sex life. Abstinence as a form of birth control and disease blocker is admirable but unrealistic.
As for the 7 infected people, even though it is unfortunate, it is better than 31. While a cure is being found, the most we can do is hope to educate and reduce the spread even if we can’t prevent the overall spread. Condoms have never promised to not transmit the disease but they are the best method for preventing the spread of HIV/AIDS while still maintaining a sex life.

 
At March 24, 2009 at 8:25 PM , Anonymous Dan said...

Emily,

"Is this at all realistic?"
Yes. They are drawing a conclusion based on empirical data (ie. what is actually observed to work).

I came across something else today that supports these conclusions:
http://www.prowomanprolife.org/2009/03/24/religious-dogma-in-africa/

"...but it is hard to change people’s minds when they aren’t properly educated and they do not necessarily believe in fidelity."
I think the idea is precisely to educate them.

"It is very hard to expect people who have led a life with sex to just give it up all together, and for people to not start a sex life."
You have so little faith in human rationality and free will. Are you telling me that you couldn't choose to give up sex entirely from this day forward if you found out today that you had HIV?

 

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