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.
What about Swaziland, which has a reputation for one of the highest HIV rates in the world? Do condoms work there? If not, what would?
As I have said, condoms have not worked in any country in Africa. The two countries with the highest infection rates, Swaziland and Botswana, have both launched MCP campaigns. "MCP" is shorthand for campaigns that discourage people from having multiple and concurrent sexual partners. We are starting to see prevalence decline in both of these countries.
Is the African church part of the problem here for creating a stigma and demonizing people with HIV?
That charge has been way overblown. There was some of that early in the pandemic, but the churches' involvement and intervention are essential. For one thing, they have always been right about where to put the emphasis — namely, on marital fidelity and abstinence, or delay of the age of first sex. All faith-based organizations promote this, whatever the denomination or religion. Faith-based organizations are some of the most powerful NGOs in Africa, and they play a leading role not only in general health and education in these countries, but also in caring for the sick and dying in the AIDS epidemics we find in Africa, from the very beginning. I think historians will look back and find great fault in the fact that the major AIDS donor organizations did really not bring the religious groups into prevention activities at or near the beginning of the pandemic.
What is the best HIV prevention strategy for the Obama administration to fund with new PEPFAR money?
Well, my views here also upset a lot of my colleagues, but I've always said that we cannot treat our way out of this pandemic. A sound public health approach is always based on good prevention strategies. We can justify treatment with expensive anti-retroviral drugs on humanitarian grounds, but it's hard to do on public health grounds.
So I would advise Obama, the candidate I voted for, to put more emphasis on prevention, and to face up to the hard realities of the best evidence available to date, which shows that condom promotion, testing and counseling, curing the curable STDs, or any of the other interventions widely endorsed and considered "best practices" always funded have simply not worked in Africa. (It's possible they may work in other regions, like condoms in Thailand, so it's easy for me to be misquoted on something like this.) In a number of studies, these interventions have actually been shown to not work.
The two interventions that work best in Africa are promotion of monogamy and fidelity, and male circumcision. We have even stronger science behind the latter. I assume people know about "the male circumcision factor" these days, so I will not say more here.
As for IDU (injecting drug use) epidemics, I would advise putting resources into preventing addiction in the first place and into treatment of drug addicts and facilitation of support groups to keep addicts from relapsing, groups like those in the 12-step programs.
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