Condoms in Africa

March 22, 2009 10:25 AM

Is this Harvard researcher citing reputable studies when he claims that: "The accepted wisdom in the scientific community 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."
posted by jsonic to science & nature (33 answers total)

The risk argument he mentions has also been used against needle exchanges.
posted by mandymanwasregistered at 10:46 AM on March 22, 2009 [1 favorite]

The only study he quotes in that particular article is his own book.

That said, he's a Harvard researcher with over 25 years of direct exposure to this particular subject (promoting condom usage in Africa, you might note), I'd venture a very solid guess that he himself has enough reputable studies under his belt to know what he's talking about, even if you don't like the sound of the conclusions he's reaching.

I'd recommend reading his book and evaluating his research process for yourself. He's written 5 other ones according to the article.

I don't have any evidence, but I do have first hand exposure to more than a dozen African cultures, some at good length, and in my personal opinion the cultural issues and the "individual" vs. "population" arguments he's making sound pretty spot on, sadly enough.
posted by allkindsoftime at 10:56 AM on March 22, 2009

If you'd like to review some of the research yourself, go to PubMed and do this search: hiv and africa and condoms

It's important to note that the interview is being reported in the Catholic News Agency.
posted by bluedaisy at 11:12 AM on March 22, 2009 [1 favorite]

First, I'm always suspicious when somebody puts the word "Harvard" in front of the word "researcher."

So I went to his page. He does run Harvard's AIDS prevention project. But when I see National Review's Rod Dreher cited as approving of him on the page, I think he's likely an ideologue. I don't see other researchers touted.

Obviously there may be no population-wide measurable benefit to condom distribution. Perhaps people don't use them enough, or don't use them during their riskeist encounters. But here are the facts folks: if a person uses condoms all the time, they have a lower chance of getting AIDS. There is no denying that. So there might be a lot of reasons why it isn't working for entire populations over there that have tons to do with cultures there. But condoms themselves make it very hard for the AIDS virus to be transmitted.

So I don't see why condom distribution should stop, especially if some old German living in the Vatican thinks it ought to be so based on what he thinks Jesus said.
posted by Ironmouth at 11:21 AM on March 22, 2009 [2 favorites]

So I don't see why condom distribution should stop

I think the researcher is making the argument that condoms paradoxically increase societal infection rates, especially when compared to behavioral programs such as promoting monogamy. That's why I'm interested in the studies he's citing.
posted by jsonic at 11:30 AM on March 22, 2009

I just read the beginning of his book on Google Books and it looks more like he's arguing that in African countries, promoting condom use isn't the most effective use of resources, rather than that condoms magically stop working in Africa, or that an individual condom isn't effective against HIV transmission.
posted by chesty_a_arthur at 11:35 AM on March 22, 2009

This very interesting article from the folks at Guttmacher make the excellent point - glossed over in the Catholic News Agency piece - that it's quite difficult to tease out which part of Uganda's ABC (Abstinence, Be Faithful, Condom) program was THE MOST EFFECTIVE. Which isn't surprising.

It's also not terribly surprising that after falling off, the infection rate begins to rise again. The same happens here in the U.S. in some populations. It's because people aren't very good at doing what's good for them, generally speaking, especially when it comes to something like sex.

I'll point my resident public health AIDS expert to this question when she gets home in a little bit.
posted by rtha at 11:41 AM on March 22, 2009

Here's another view of the matter (I pasted some bits to summarize it):

Uganda’s first AIDS control programme was set up in 1987 to educate the public about how to avoid becoming infected with HIV. The programme promoted the ABC approach (abstain, be faithful, use condoms), ensured the safety of the blood supply and started HIV surveillance.

It is thought that the government’s ABC prevention campaign was partly responsible for the decline in prevalence. However, as treatment was not widely available in Uganda during this time the high numbers of AIDS-related deaths also contributed to the reduction in the number of people living with HIV.

Free antiretroviral drugs have been available in Uganda since 2004. It is thought that the availability of drugs to treat HIV may have led to complacency as AIDS is no longer an immediate death sentence; this may have contributed to the suspected rise in new HIV infections.

Many experts have also speculated that Uganda’s shift in prevention policy away from ABC towards US-backed abstinence-only programmes may also be responsible for an increase in risky behaviour, as comprehensive sex education and condom promotion are no longer mainstream.
posted by lucia__is__dada at 11:41 AM on March 22, 2009 [1 favorite]

You should note that it isn't the researcher who is claiming increased infection rates from condom promotion. "Found the opposite to be true" is not a quote in the original article, but an editorial comment.

That said, if the question is whether or not condoms lower infection rates societally, I don't know the answer. I do know, however, that every time a couple uses a condom during sex, the risk of HIV infection if the couple is serodiscordant is lowered dramatically.
posted by OmieWise at 12:16 PM on March 22, 2009

Anyone who so seriously misrepresents harm reduction sets off a lot of red flags for me. I do not know him, nor am I familiar with his research, but the fact that he is mischaracterizing a very well-known intervention modality (and one strongly disliked in conservative political circles) makes me think that he has a specific political and ideological axe to grind here.
posted by gingerbeer at 12:16 PM on March 22, 2009 [2 favorites]

More detailed information about what has been happening in Uganda, including this excerpt:

Despite the evidence that condoms are one of the many tools necessary to combat the spread of HIV, a culture of fear and mistrust has been well cultivated in Uganda. The leadership in Uganda has taken action to impede the free access to accurate information and counseling on condom use, supported by PEPFAR-backed programs and guidelines. Since this war against condoms was initiated in 2004, HIV prevalence has increased at an alarming rate, giving valid cause for alarm. Uganda has been touted as the model of ABC success, but the ABC model is no longer promoted and implemented in the same, balanced method as before. While no single strategy offers a panacea to the HIV/AIDS epidemic, if Uganda is to once again bring the epidemic back into check, it will need to draw on all available resources, including condoms.
posted by gingerbeer at 12:38 PM on March 22, 2009 [1 favorite]

When I first read your question, I thought that the researcher would be some kind of nut. But, no.

To find cites without purchasing any of his books, you can look at this presentation he gave. Basically, it's a PDF of the PowerPoint slides, with speaker notes. He cites studies done, which added to his research.

This is a researcher dedicating his life to the AIDS issue. Harvard employs him (not exactly a hotbed of fundies). There's a difference between first-hand (what the researcher says) and second-hand (how the Catholic News Agency interprets and presents what the researcher says).
posted by Houstonian at 1:01 PM on March 22, 2009

To see more of his publications, go to this page at the AIDS Prevention Research Project at Harvard. It has his CV and a linked list of his publications. It's a pretty impressive list, frankly. He's written over 250 peer-reviewed articles. His latest book got positive mention in Lancet.
posted by Houstonian at 1:07 PM on March 22, 2009

While there are obviously many factors, Senegal has one of the lowest infection rates in Sub-Saharan Africa at under 1%, and under 20% among sex workers, and strong promotion of condom use is widely cited as part of the reason for that.

More info from wikipedia
posted by Nothing at 1:41 PM on March 22, 2009 [1 favorite]

It's not an incredibly surprising finding, I don't think. Ignoring the potential controversy about condoms in particular, studies have found that safety equipment tends to encourage riskier behavior. This study, for instance. Or this salon article that describes how more traffic control signage seems to lead to increased accidents.
posted by logicpunk at 2:06 PM on March 22, 2009

on the blue.
posted by greta simone at 4:40 PM on March 22, 2009

It doesn't necessarily prove anything, but I think the fellow's background is pretty pertinent to this discussion.
posted by es_de_bah at 5:51 PM on March 22, 2009

So....this dude claims to have tons of "selected" publications, but I don't recognize MOST of these papers as being from a legitimate scientific journal.

He can publish "The ABC Approach to Preventing the Sexual Transmission of HIV: Common Questions and Answers", wherever he wants, but we should acknowledge that it is published for Christian Connections for International Health.

So yeah...say what you want, but don't say its SCIENCE. Tell us that these findings are published for faith based organizations and think tanks.

Christ, what an asshole.
posted by hal_c_on at 8:38 PM on March 22, 2009 [1 favorite]

hal_c_on, he's been working on AIDS prevention, including extended periods in some extremely desolate areas, for the last 20+ years. You don't agree with him, fine, but your last comment is ludicrous and makes you look small.

As for the publications, check the CV. I do not read the Journal of the A.M.A., perhaps it's not up to snuff as a scientific journal?
posted by txvtchick at 9:27 PM on March 22, 2009

He's an anthropologist and the AMA article he published was a book review.
posted by bluedaisy at 2:22 AM on March 23, 2009

Does the AMA typically have non-subject matter experts conduct reviews? Is his CV, including his body of published works, indicative of a lack of knowledge or expertise?
posted by txvtchick at 6:32 AM on March 23, 2009

I don't know that it's in question that he's a non-expert - he's clearly done tons of research in HIV in Africa. But a book review is not the same as a peer-reviewed study. He's published articles in peer-review publications, but the book review in the AMA journal isn't one of them.
posted by rtha at 11:22 AM on March 23, 2009

hal_c_on, he's been working on AIDS prevention, including extended periods in some extremely desolate areas, for the last 20+ years. You don't agree with him, fine, but your last comment is ludicrous and makes you look small.

I may be small, but I understand how science works.

I've known all sorts of people to be involved in all sorts of humanitarian causes. Just because they do so, does not give them the right to use their experience as a validation of science for their faith-based beliefs when they have no science to back it up.

Otherwise, I'll say that:

Going to church is better than wearing seat belts. When people wear seat belts, it gives them a sense of safety, and they drive even more dangerously. This new style of driving then ultimately kills them at a greater rate than driving as if they didn't have seat belts on.

Oh, and just like Dr. Green, I don't have any accepted methodology to my research, nor do I have any significant statistics. All I have is the experience from about 20 years of driving.

Thats the same thing, right?

As for the publications, check the CV. I do not read the Journal of the A.M.A., perhaps it's not up to snuff as a scientific journal?

He is a scientist. He has done research on subjects. But being published in JAMA for subject matter A, doesn't mean you have any authority when you are talking about faith-based matter B. Thats not science, its BS.
posted by hal_c_on at 11:50 AM on March 23, 2009

If you're going to worship at the altar of science, then at least be pious about it. Empirical evidence is the foundation of science. He clearly has the experience and education to speak and publish about the topic. Even if you disagree with his conclusions, calling him an asshole and snarking about his qualifications isn't just small, it's anti-science.
posted by txvtchick at 12:10 PM on March 23, 2009

Neither his CV nor the presentation linked to seem to indicate any expertise in epidemiology (i.e., the science of disease in human populations). His methods seem to be anthropological and his quantitative skills as indicated by his presentation are rudimentary at best. He also fails to cite the vast epidemiologic literature on AIDS in Africa, so I'm feeling little love for the guy's conclusions. YMMV.
posted by Mental Wimp at 3:46 PM on March 23, 2009 [1 favorite]

No, he's not an epidemiologist. As bluedaisy pointed out his field is anthropology, specifically medical anthropology. Studying the effectiveness of condom use at a population level would seem to fall reasonably within that field. The presentation Houstonian linked to was a presentation to donors of the Kellogg Foundation so I assume it was written for a lay audience.

That said - I have no idea whether he is correct or not. None of the links posted in this thread are to a study which contradicts or confirms the statement, "We just cannot find an association between more condom use and lower HIV reduction rates in Africa." I just get irritated by the presumption that because someone apparently identifies with a particular religion, their views - and in this guy's case, his substantial education and experience - cannot possibly be valid.
posted by txvtchick at 8:13 PM on March 23, 2009 [1 favorite]

None of the links posted in this thread are to a study which contradicts or confirms the statement, "We just cannot find an association between more condom use and lower HIV reduction rates in Africa."

You did see the link here, yeah?
posted by rtha at 8:43 PM on March 23, 2009

The SEICUS one? Yeah I did. It says:
- "Since this war against condoms was initiated in 2004, HIV prevalence has increased at an alarming rate"
- "HIV prevalence rates in Uganda continue a downward trends"

And it doesn't show data to support either position. So no, I don't think that article does the trick.

- This article discusses a study which argues that the reduction in prevalence was due to the death of many of those infected. It also says:
"...while condom use has increased sharply over the last ten years, this has been counterbalanced by increases in other sexual risk behaviour and that Ugandans, at least in Rakai, appear to be less abstinent and less faithful than they were."

- This one might be more along the lines of what you're looking for: "There is no question that the condom crisis in Uganda is being driven and exacerbated by [the US President's Emergency Plan for AIDS Relief (criticized by the SEICUS article as favoring abstinence only programs)]" he said, adding that this "undoubtedly will cause significant numbers of infections which should never have occurred".

But it still doesn't offer data to support that. And also says: "[the study author] presented some behavioural data...which suggest that there has been a corresponding change in risky behaviour since 2000...'condom use doesn't appear to have changed very much'.
posted by txvtchick at 8:09 AM on March 24, 2009

If you're going to worship at the altar of science, then at least be pious about it. Empirical evidence is the foundation of science. He clearly has the experience and education to speak and publish about the topic. Even if you disagree with his conclusions, calling him an asshole and snarking about his qualifications isn't just small, it's anti-science.
posted by txvtchick at 12:10 PM

I'm using facts to back up my arguments. You're just insulting me because I don't bow to his faith-based argument. I'm leaving this thread and will let the others who respect and UNDERSTAND how science works finish you off.

In the future, you may want to not make your Texas roots apparent, TXvtchick. It makes texas sound like the kind of place that most non-texans think it is: anti-science at the expense of those who don't have the $$s.
posted by hal_c_on at 9:46 AM on March 24, 2009

Sigh.

UNAIDS/WHO statement on condoms, with references

Prevention of transmission of human immunodeficiency virus in Africa: effectiveness of condom promotion and health education among prostitutes.

HIV incidence and sexually transmitted disease prevalence associated with condom use: a population study in Rakai, Uganda This study found that consistent use of condoms reduced disease transmission, and inconsistent use did not.

Sexual abstinence, contraception, and condom use by young African women: a secondary analysis of survey data

The Culture of Condoms: Culturally Grounded Variables and Their Association With Attitudes to Condoms Covers the cultural acceptance of condoms.

That's on a very quick sweep through Google Scholar. Not really all that difficult to find, and yes, many researchers have in fact found a positive association between condom use and decreased HIV transmission in Africa.
posted by gingerbeer at 10:33 AM on March 24, 2009 [1 favorite]

From gingerbeer's 2nd link:

Any condom use resulted in a 3-fold reduction in risk of seroconversion.

Thanks for those citations!
posted by Mental Wimp at 1:33 PM on March 24, 2009

Not really all that difficult to find, and yes, many researchers have in fact found a positive association between condom use and decreased HIV transmission in Africa.

Please post one, then. You're not addressing the question and it doesn't seem like you've read the original article, any of the upstream links, or anything about what Green is arguing. To recap:

"We just cannot find an association between more condom use and lower HIV reduction rates in Africa," the article quotes Green as saying. Jsonic wants to know whether Green is citing reputable studies or not.

According to the presentation that Houstonian - how can Texas possibly withstand all these hits to its reputation? - linked to, Green believes that:

1. Condoms are effective in reducing risk of HIV transmission when used consistently and correctly under optimal conditions.
2. Inconsistent condom use produces little or no reduced risk
3. "inconsistency of use, disinhibiton, and non-use by married and ongoing couples lead to condoms having little/no impact at population level"

Let's look at the spaghetti on the wall, then:

UNAIDS/WHO statement on condoms, with references
The reference for the "condoms help prevent the spread of HIV in countries" statement in that link is this work, which is a discussion of the ABC approach in Uganda. Rtha already posted it upstream, and as he notes it doesn't draw any conclusions on what part of ABC worked.

Prevention of [HIV] transmission in Africa: effectiveness of condom promotion...among prostitutes.
From the original article, "Green’s research found that 'condoms have been effective' in HIV concentrated areas where high risk activities are already being conducted, such as brothels in countries like Thailand." Maybe behavioral disinhibition is not a factor for the prostitutes at this point in their lives.

HIV incidence and sexually transmitted disease prevalence associated with condom use...
Green cites this study as a reference for point #2 above. If anything, it supports his position.

And your last two links don't really touch on the question at all. If you have seen a study which supports or does not support the premise that condoms reduce HIV prevalence at the population or country level in Africa, please post it.
posted by txvtchick at 7:18 PM on March 24, 2009

Here's relevant data point from UC Berkley:

"For example, condom use is widely promoted as an HIV prevention measure and is effective in countries such as Thailand, where the epidemic is spread primarily by sex workers. However, studies have found no evidence that condom use has played a primary role in HIV decline in generalized, primarily heterosexual epidemics, such as those in southern Africa, the authors note. This is mainly because most HIV transmission there occurs in more regular sexual relationships, in which achieving consistent condom use has proved extremely difficult."
posted by txvtchick at 7:31 PM on March 24, 2009