NEW YORK, SEPT. 24, 2005 ( Critics continue to assail the Catholic Church's refusal to endorse condom use in treating the AIDS problem. Among recent attacks was in the medical journal The Lancet. "[F]aith seems to present insuperable obstacles to the prevention of disease," asserted an editorial dated March 12. "Nowhere is this problem more acute than in HIV/AIDS."

The editorial was highly critical of Pope John Paul II for his opposition to condom use, accusing him of being ignorant of African history, culture and the realities of daily life in the continent.

On May 8, New York Times editorial page commentator Nicholas Kristof accused the Church of having cost hundreds of thousands of lives due to its refusal to endorse condom use.

Kristof expressed the hope that the recently elected Benedict XVI would not only change the Church's position on this issue, but would indeed "encourage the use of condoms," affirming it would be a "courageous choice."

The decision by the U.S. government to limit its funding for condoms has also come in for criticism. According to an Aug. 30 report in the British newspaper Guardian, Stephen Lewis, the U.N. secretary-general's special envoy for HIV/Aids in Africa, said that U.S. cuts in funding were damaging Africa. He also described the Bush administration of following a "dogma-driven policy" on the issue.

And the New York Times once again weighed in on the matter, in an editorial Sept. 4. The editorial argued that by limiting condom availability, the reduction of AIDS in Uganda was being put at risk.

More Catholics, fewer infections

Abundant data exist, however, to show the severe limitations of relying on condoms to solve the AIDS problem. A letter from Australian-based bioethicist Amin Abboud, published July 30 by the British Medical Journal, noted that any change in the Catholic Church's position on condoms would be detrimental for Africa.

According to Abboud, a statistical analysis of the situation in the continent shows that 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," he added, "it seems to be working."

Data from the World Health Organization puts the figure for HIV infection in Swaziland 42.6% of the population. Only 5% of the population is Catholic. And in Botswana, where 37% of the adult population is HIV infected, only 4% of the population is Catholic. In Uganda, however, where 43% of the population is Catholic, the proportion of HIV infected adults is 4%.

Abboud commented that since the death of John Paul II there has been a "concerted campaign ... to attribute responsibility to him for the death of many Africans." But, he continued, "Such accusations must always be supported by solid data. None has been presented so far."

Recognition of the value of promoting abstinence, instead of just relying on condoms, came in a commentary published in The Lancet last Nov. 27. Written by a group of medical experts, and endorsed by a long list of health care experts, the article noted that when campaigns target young people who have not initiated sexual activity, "the first priority should be to encourage abstinence or delay of sexual onset, hence emphasizing risk avoidance as the best way to prevent HIV and other sexually transmitted infections as well as unwanted pregnancy."

The article did support condom use, but also pointed out that even for those who have already engaged in sexual activity, "returning to abstinence or being mutually faithful with an uninfected partner are the most effective ways of avoiding infection." This goes even for adults: "When targeting sexually active adults, the first priority should be to promote mutual fidelity with an uninfected partner as the best way to assure avoidance of HIV infection," stated the article.

This argument is based on solid medical evidence, the authors pointed out: "The experience of countries where HIV has declined suggests that partner reduction is of central epidemiological importance in achieving large-scale HIV incidence reduction, both in generalized and more concentrated epidemics."

Questioning orthodoxy

Recent information on the situation in Uganda, which is often cited as an example of how programs advocating abstinence and fidelity to partners can reduce the incidence of AIDS, confirms the position of those who question relying on condoms.

A report published Sept. 13 on Aidsmap, a United Kingdom Web site dedicated to distributing information on AIDS, summarized the findings of a study published in the Sept. 1 issue of the Journal of Acquired Immune Deficiency Syndromes.

The study demonstrated that while campaigns to distribute and promote condoms in Uganda did increase usage, they did not lead to consistent use. Moreover, men in the group targeted by the campaigns then "went on to have a larger number of sexual partners and were somewhat less likely to use condoms with casual sex partners than the control group."

The findings, noted Aidsmap, "raise uncomfortable questions about the evidence base that informs the current international orthodoxy in HIV prevention."

The study compared two groups recruited from poor urban communities in Kampala. Another conclusion was that "improved availability of condoms in Uganda has had only a modest effect on condom uptake."

Changing behavior

This latest study confirms the arguments made by Edward Green, in his 2003 book, "Rethinking AIDS Prevention." Green is a senior research scientist at the Harvard Center for Population and Development Studies and a member of the President's Advisory Committee on HIV/AIDS.

Green does not have moral objections to condoms, and, in fact, has worked in the past with organizations that promote contraceptives and family planning programs. Nevertheless, he raises serious doubts about the wisdom of fighting AIDS by relying on condom distribution.

In Africa, repeated population surveys show that the most common behavioral change in response to the diffusion of AIDS is an increase in the fidelity to one's partner, the reduction of sexual partners, and sexual abstinence. When, in addition to this spontaneous response, this type of change is promoted through campaigns, then we are building on what people naturally do, Green argued. Unfortunately, he added, foreign experts only too often arrive and impose campaigns that ignore the benefits of behavioral changes, preferring to rely on distributing condoms.

In addition, Green cites studies showing that condom promotion campaigns do not lead to long-term consistent use. And inconsistent use is associated with a higher risk of sexually transmitted diseases. In fact, the African countries with the highest condom user rates and numbers of condoms available, Zimbabwe and Botswana, also rank at the top of the list for rates of HIV infection.

Neither are condoms infallible, particularly those typically available in African countries, Green observes. In fact, condoms are widely held to be one of the least effective methods of contraception, yet paradoxically, are promoted by experts as the answer to preventing AIDS. This is not to say, Green points out, that the use of condoms causes AIDS, "only that condoms might give men a somewhat greater sense of security than warranted by actual condom effectiveness."

Independently of these debates, the new Pope quickly gave an answer to those pressing for changes in Church doctrine. Addressing the bishops from a group of southern African countries on June 10, Benedict XVI urged them to continue supporting family life and to help those suffering from AIDS.

The Catholic Church, commented the Pontiff, "has always been at the forefront both in prevention and in treatment of this illness." And, he added: "The traditional teaching of the Church has proven to be the only fail-safe way t o prevent the spread of HIV/AIDS."