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Edward C. Green is one of the world's leading field researchers on the spread of HIV and public health interventions. He's the director of the Harvard AIDS Prevention Research Project, and is a leading advocate for evidence-based interventions. He has been sharply criticized by some public health experts for supporting sexual partner reduction programs and for endorsing the so-called ABC method ("Abstain, Be faithful, or use a Condom") for fighting the transmission of HIV. After Pope Benedict's comments earlier this week, Green agreed to answer Christianity Today deputy managing editor Tim Morgan's questions by e-mail.

Is Pope Benedict being criticized unfairly for his comments about HIV and condoms?

This is hard for a liberal like me to admit, but yes, it's unfair because in fact, the best evidence we have supports his comments — at least his major comments, the ones I have seen.

What does the evidence show about the effectiveness of condom-use strategies in reducing HIV infection rates among large-scale populations?

It will be easiest if we confine our discussion to Africa, because that's where the pope is, and that is what 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, the 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 of condoms in Africa in 1988.

Is there any country worldwide (Brazil or Thailand, for example) that has emphasized condoms where a reduction in HIV infections has been verified and sustained?

In countries where HIV is largely concentrated among prostitutes and their clients, such as Thailand and Cambodia, there seems to have been success in promoting the so-called 100 percent condom policy in brothels. Most analysts credit the decline of HIV infection rates there to this policy and its implementation (of course, they were saying that about Uganda as well), but I agree that this probably has been the major factor explaining prevalence decline in those two countries. However, condom use is not especially high for prostitutes and their clients who are not based in brothels. And another factor in both countries is surely that there was a significant decline in the proportion of men going to prostitutes of any sort, and there was even a big decline in the proportion of men having extramarital sex in the years before we first saw infections decrease in Thailand.

Is there any country in Africa with a high HIV infection rate that has implemented new programs and seen infection rates fall? If so, what strategies are being followed?

I'm glad you asked this. We are seeing HIV decline in eight or nine African countries. In every case, there's been a decrease in the proportion of men and women reporting multiple sexual partners. Ironically, in the first country where we saw this, Uganda, HIV prevalence decline stopped in about 2004, and infection rates appear to be rising again. This appears to be in part because emphasis on interventions that promote monogamy and fidelity has weakened significantly, and earlier behavior changes have eroded. There has been a steady increase in the very behavior that once accounted for rates declining — namely, having multiple and concurrent sex partners. There is a widespread belief that somehow Uganda had fewer condoms. In fact, foreign donors have persuaded Uganda to put even more emphasis on condoms.

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March (Web-only) 2009, Vol. 53