di Rodolfo Casadei

According to Harvard professor Edward Green, Benedict XVI tells the truth about fighting the plague of the millennium in Africa: fidelity and abstinence promotion are better weapons than preservatives

During his latest visit to Africa pope Benedict XVI told the journalists: “Condom distribution is not the solution to Aids, on the contrary they worsen it”. An editorial comment of The Lancet retorted that the Pope's comment was “outrageous and wildly inaccurate”. Based on your experience about the issue, is the Pope right or wrong?
As I have said in the Washington Post and elsewhere, the Pope is basically right – about Africa. It will be easiest if we confine our discussion to Africa, because that’s where the Pope was en route to and that is the place he was talking about. There’s no evidence at all that condoms have worked as a public health intervention intended to reduce HIV infections, at the “level of population.” This is a bit difficult to understand. It may well make sense for an individual to use condoms every time, or as often as possible, and he may well decrease his chances of catching HIV. But we are talking about programs, large efforts that either work or fail at the level of countries, or, as we say in public health, level of population. Major articles published in Science, The Lancet, British Medical Journal, and even Studies in Family Planning have reported this finding since 2004. I first wrote about putting emphasis on fidelity instead off condoms, in the book AIDS in Africa, in 1988.
Condoms fail because people do not use them consistently, because they are not used once people get to know someone, and because they provide a false sense of security, allowing people to take greater risks then they would take if condoms were not used at all. They also divert resources from interventions that work better, such as promoting faithfulness.

In your books and articles you emphasize that the ABC approach in Africa works. At first sight it doesn't sound possible, since Abstinence, Partners sexual fidelity and Condom are three very different things. What's the right dosing of the three?
Abstinence and fidelity are different from condom use. They avoid the risk of infection altogether (assuming mutual fidelity). This approach is also known as risk avoidance. Condom use introduces risk; it not a form of risk avoidance, but rather risk reduction. Consistent condom use is only 80-85% protective when practiced consistently, although under real-life conditions, such as those most of us live in, condom use is much less protective. We actually knew condoms were not very effective for HIV prevention, from our experience with family planning, before the advent of AIDS.
Part of the genius of Uganda’s original ABC program is that it addressed the immediate or “proximate” causes of HIV infection, namely avoiding the risk of infection, reducing the risk of infection, or decreasing the efficiency of infection. It separates these basics from all the other things that might or might not be involved (such as poverty, gender inequality, human rights, stigma, etc).

What are the most important things about Aids and Africa that the outside world, and especially journalists, seem not to understand?
That we cannot have complete Sexual Freedom and effective prevention at the same time; that Africa is different from the rest of the world (because condoms do work quite well in some types of epidemics); and that sexual behavior must change in basic ways for HIV infection rates to decline (except that there is an epidemic curve effect, that will temporarily make infection rates go down for a period, after those at highest risk of infection have died off faster than new cohorts enter the sexually active years).

Why, in your opinion, did international organizations and governments react so harshly to the Pope's words? Do they really believe that condoms are tool N.1 for Aids prevention, or are they influenced by some vested interests they have, and that we suspect but can't see?
They reacted as they did for a number of reasons, starting with the deep-rooted belief that condoms work much better than they actually do. We cannot really blame journalists for being ignorant of the evidence, especially when leading experts keep saying that condoms are the number one weapon we have against AIDS. And yes, people including scientists are influenced by vested interests (most American money for AIDS prevention goes through family planning or reproductive health organizations.) A factor usually overlooked is the ideology of sexual liberation. Those of us who work in AIDS don’t realize how much the values and ideology of sexual freedom and liberation influence our thinking. It helps explain why until very recently, faith-based organizations were largely excluded from AIDS prevention even though FBOs run many of the hospitals, clinics and schools in Africa. It also explains the strong emotional reactions we see when the AIDS establishment is challenged.

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Which is the best “best practise” you have encountered in Africa? And which is the worst official intervention you have witnessed?
I use the Uganda ABC program as a model that the rest of us should follow. This model can be seen especially in the period 1986 until the early 1990s, by which time outside donors and funders began to change Uganda’s program to the point that it now resembles any other program in Africa. The ABC program used to emphasize partner fidelity above all else. It promoted abstinence primarily for young people not yet sexually active. It was very cautious and low-key about promoting condoms. Since the mid-1990s, the distinctive features of this program have been lost and condoms along with testing and drugs have become by far the most important feature. In recent years, HIV prevalence has started to go up again.
As for the worst program, one does not need to look very far. All programs are heavily condom based, and condoms are only clearly effective in some types of epidemics. Even in these countries, such as Thailand and Cambodia, it is not clear how much condoms contribute and how much more fundamental types of behavior change (such as not going to prostitutes, not having extramarital sex) contribute. The other elements we see in all programs include testing and counseling, treating STDs, and things such as human rights and income generation. None of these interventions have been shown to work, and some, such as testing, have shown to probably not work in Africa.

In order to avoid Aids, is it more practical and feasible to teach Africans a “consistent use” of condom or primary sexual behavior change?
Primary behavior change. We can teach consistent condom use, but we know by now that very few people will practice it.

Today, late June 2009, do Third World countries exist which have succeeded in reducing HIV prevalence? How did they get that outcome?
We see prevalence decline in 8 or 9 countries in Africa today. In every case, we first see a decline in the proportion of men and women who report more than one sex partner in the previous year. But it is hard to attribute this behavior change to national programs. Most national programs don’t even deal with sexual behavior beyond condom adoption. I think we see this more or less spontaneous behavior change because people have started to see what works and what does not. It is also possible that religious organizations have helped change behavior, in spite of national programs that miss the mark.

In your book you have written: “Whatever the failure rate of condoms in contraception, it should be higher in HiV prevention” (p. 97). This sends shivers down the spine. How high is failure rate of condoms in contraception?
It is about 75-80%. The two rates are probably comparable. I was referring in my book more to the fact that pregnancy can only occur during certain days of a woman’s cycle, whereas HIV infection can occur at any time.

Some statistics show that African countries where condoms are more easily available, are the same countries where Aids incidence is higher. Does this mean that condom distribution worsened the situation, as the Pope said?
It is hard to answer this. We do have studies that show how inconsistent condom use – which is also typical condom use – is worse than no condom use. And there is a prospective study in Uganda showing that intense condom promotion leads to riskier sexual behavior, along with suggestive evidence that this occurs elsewhere

What do your peers and colleagues in Harvard think about your stands? Did anybody boycott you? Did you lose friends and career chances?
I don’t have much support. Our program is in fact leaving Harvard.

Your HIV Prevention Research Project at Harvard is ending and it will not be renewed. Is it because of your politically incorrect ideas? What are you doing now?
I would rather not answer this question. You might ask someone at Harvard what they think. I am writing two books about AIDS. One is called AIDS and Ideology. I still have foundation support and I still have about 6 more months at Harvard.

Are you Catholic, or a Christian, or any kind of a religionist?
I believe in the God of my own understanding but belong to no church or religious group.

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