Tuesday, March 31, 2009

That Article About Condoms in Africa

I wanted to blog about this editorial in The Post over the weekend, but ended up getting caught up in other things. There was an interesting opinion piece about the use of condoms to fight the AIDS epidemic in Africa. This anthropologist says that condoms are not the right solution to that particular problem, and here he explains his reasoning. You may find this interesting.

The editorial is too long to reproduce in full here, so I'll pick and choose.
When Pope Benedict XVI commented this month that condom distribution isn't helping, and may be worsening, the spread of HIV/AIDS in Africa, he set off a firestorm of protest. Most non-Catholic commentary has been highly critical of the pope. A cartoon in the Philadelphia Inquirer, reprinted in The Post, showed the pope somewhat ghoulishly praising a throng of sick and dying Africans: "Blessed are the sick, for they have not used condoms."

Yet, in truth, current empirical evidence supports him.

We liberals who work in the fields of global HIV/AIDS and family planning take terrible professional risks if we side with the pope on a divisive topic such as this. The condom has become a symbol of freedom and -- along with contraception -- female emancipation, so those who question condom orthodoxy are accused of being against these causes. My comments are only about the question of condoms working to stem the spread of AIDS in Africa's generalized epidemics -- nowhere else. The Pope May Be Right

The anthropologist, Edward C. Green, cites a couple of studies that showed that promotion of condom use did not reduce the rate of transmission of AIDS in Africa, then says:
Let me quickly add that condom promotion has worked in countries such as Thailand and Cambodia, where most HIV is transmitted through commercial sex and where it has been possible to enforce a 100 percent condom use policy in brothels (but not outside of them). In theory, condom promotions ought to work everywhere. And intuitively, some condom use ought to be better than no use. But that's not what the research in Africa shows.

Why not?

One reason is "risk compensation." That is, when people think they're made safe by using condoms at least some of the time, they actually engage in riskier sex.

Another factor is that people seldom use condoms in steady relationships because doing so would imply a lack of trust. (And if condom use rates go up, it's possible we are seeing an increase of casual or commercial sex.) However, it's those ongoing relationships that drive Africa's worst epidemics. In these, most HIV infections are found in general populations, not in high-risk groups such as sex workers, gay men or persons who inject drugs. And in significant proportions of African populations, people have two or more regular sex partners who overlap in time. In Botswana, which has one of the world's highest HIV rates, 43 percent of men and 17 percent of women surveyed had two or more regular sex partners in the previous year.

These ongoing multiple concurrent sex partnerships resemble a giant, invisible web of relationships through which HIV/AIDS spreads. A study in Malawi showed that even though the average number of sexual partners was only slightly over two, fully two-thirds of this population was interconnected through such networks of overlapping, ongoing relationships.

So what has worked in Africa? Strategies that break up these multiple and concurrent sexual networks -- or, in plain language, faithful mutual monogamy or at least reduction in numbers of partners, especially concurrent ones. "Closed" or faithful polygamy can work as well.

One interesting phenomenon here is that people use condoms when they think they are at risk. So, for one thing, if you have a regular partner and you pull out a condom they may see it as a sign that you don't trust that they are faithful to you, or you may be afraid they will think that. For another thing, as he notes here, men are most likely to use a condom with a prostitute, and so statistics showing an increase in condom use may actually not be so very heartening, it might mean more "commercial" sex, he calls it, sex with prostitutes. And given that condoms break and that people in some countries are not trained in their correct use, more sex with prostitutes is likely to result in greater spread of disease. Using a condom may make a man feel safer, so he engages in riskier behavior.

If you've been reading the blog for a while you might know that I am interested in using social networks to understand the propagation of STDs, especially HIV. For instance, I talked about it HERE. We have people who talk about risky behaviors -- the classic example is anal intercourse -- as if the behavior itself puts you at higher risk for getting AIDS, but in fact the risk is zero if your partner is not infected. With HIV especially, any sexual interaction with an infected person carries a risk, it hardly matters what you do, it matters a lot who you do it with.

Faithful mutual monogamy is an excellent deterrent to STD propagation. If everyone only had sex with one person, all sexually transmitted diseases would simply die out. (At least the ones that are transmitted exclusively through sex would; diseases such as herpes simplex and HPV that can be communicated through incidental contact would be reduced in prevalance but would survive.) The social network in the perfect faithful monogamy model is a set of discrete dyads, or social units of two persons, disconnected from other dyads, and there is simply no way for a disease to spread through a population in that configuration.

Social network research since the seventies has shown "the strength of weak ties," the importance of casual social relationships for propagating information (including infectious diseases) through a population; more recently, "small worlds" have been a focus of social network research, again showing that random connections can bring distant groups of people closer to one another. In the current example, a random connection can cause wider, faster spread of an infectious disease.

There was an interesting study a few years back, you can read a summary and see the graph HERE. It is the social network of sexual relations at a high school, they made a map of every student who had sex with another student. You see there is a big cluster of students who mostly had two partners, some had as many as four, it looks like -- I see one guy who had sex with nine different girls and one girl who had six guys -- and partners had partners, connecting a large part of the school community. But in this same graph there were sixty three closed dyads, couples who only had sex with one another, and there were twelve boys who had sex with two girls who only had sex with them, plus nine girls who only had sex with two boys who only had sex with them. These disconnected little clusters of two and three are at no risk of infection, assuming there were not links out of the school community. Anyone in the big cluster is at risk, once an infection is introduced to the group everyone can end up with it, depending on how the relationships are arranged in time. This anthropologist is saying that there are communities in Africa that look like the big cluster, and somehow that needs to be modified into discrete groups, like those 63 dyads.

The reason HIV spreads in Africa and other places is that people do not practice faithful monogamy. And you know what they say, when you have sex with someone you are having sex with everyone they had sex with. The more densely connected the network of sex partners and partners of partners, the more likely a disease can spread through that entire network.

The mention of faithful polygamy is interesting, too. It's not much of a recommendation in our society, but there may be African communities where polygamy is practiced. The point is that the local network of sex partners should be isolated, so infection does not flow in and out of the immediate group. If you have five wives, and you only have sex with them, and they only have sex with you, the "faithful monogamy" conclusion still applies. And yes, ladies, the same is true if you have five husbands. As long as all individuals are free of infection there is no risk. The problem there of course is that as the numbers of ...spouses? ... increases, the probability that any one of them will be unfaithful increases, as well, meaning the probability of bringing an infection into the marriage is increased. And then instead of infecting one other person, all partners can end up infected. So the probability of infidelity increases and its impact also increases.

None of this has anything to do with sexual orientation, by the way. AIDS spreads as easily through heterosexual populations as homosexual ones. Monogamous, married gay couples where neither person is infected have nothing to worry about. Well, they still have to figure out who's going to get the remote.

Oddly, I met the anthropologist who wrote this piece a couple of weeks ago. He is a friend of one of the guys in the band I play in, and he and his wife came to our gig out in Germantown. The seemed like good people, we talked about microtones in Persian music.

A little more...
Don't misunderstand me; I am not anti-condom. All people should have full access to condoms, and condoms should always be a backup strategy for those who will not or cannot remain in a mutually faithful relationship. This was a key point in a 2004 "consensus statement" published and endorsed by some 150 global AIDS experts, including representatives the United Nations, World Health Organization and World Bank. These experts also affirmed that for sexually active adults, the first priority should be to promote mutual fidelity. Moreover, liberals and conservatives agree that condoms cannot address challenges that remain critical in Africa such as cross-generational sex, gender inequality and an end to domestic violence, rape and sexual coercion.

The AIDS epidemic is changing in the US. What started as a scourge of gay men and hypodermic needle users has evolved into an epidemic among heterosexuals, especially among the black community. You may have seen the recent news that three percent of the residents of Washington DC now have HIV. In the 40-49 age group, 7.2 percent of people are HIV-positive. 6.5 percent of black men in DC have it. The AIDS epidemic now in our local urban center is worse than it is in West Africa.

If everybody used a condom every time they had sex, the epidemic would shrink to nearly nothing. But that isn't going to happen, people especially tend not to use a condom with a regular partner, and that regular partner just might have another regular partner. If everybody was faithful to one partner, even without condoms the epidemic would shrink to nearly nothing. This anthropologist is saying that's what has to happen in Africa. How do you get that to happen? He doesn't explain that part of it.


Anonymous Robert said...

Two other factors that I would think affect the incidence of HIV infection are testing and treatment: testing, because people change their behavior if they know they or their partner are HIV-positive; and treatment, because Highly Active Anti-Retroviral Therapy has been shown to dramatically reduce the chance that someone who is positive can transmit the infection.

I know that treatment in most African countries is dismal; would I be wrong to speculate that testing is also under-utilized?

As for the Pope: I would venture to say that his opposition to condom use in not based on HIV statistics; it is based on Catholic theology, specifically De Humanae Vitae (every sperm is sacred), which specifies that contraception, any contraception, is sinful. Speaking of which, what percentage of American Catholics don't use contraception at some point? The pregnancy rate among American Catholics answers that. Papa Ratzi choses those HIV stats which seem to lead to the same conclusion as De Humanae Vitae; he is not perusing the literature to decide what methods are most effective in limiting the epidemic. In other words, the theology is more important than human life and misery.

My apologies to my Catholic brethren and sisters, but that's how I see it.

March 31, 2009 4:17 PM  
Anonymous Robert said...

Here's an article on HAART and HIV-infection rates: HAART may reduce HIV infections by up to 60%

March 31, 2009 4:21 PM  
Anonymous Derrick said...

I would just like to point out the differences between HIV and AIDS:

H - Human: because this virus can only infect human beings.
I - Immuno-deficiency: because the effect of the virus is to create a deficiency, a failure to work properly, within the body's immune system.
V - Virus: because this organism is a virus, which means one of its characteristics is that it is incapable of reproducing by itself. It reproduces by taking over the machinery of the human cell.

A - Acquired: because it's a condition one must acquire or get infected with; not something transmitted through the genes
I - Immune: because it affects the body's immune system, the part of the body which usually works to fight off germs such as bacteria and viruses
D - Deficiency: because it makes the immune system deficient (makes it not work properly)
S - Syndrome: because someone with AIDS may experience a wide range of different diseases and opportunistic infections.

We call HIV "AIDS" when a person´s CD4 cell count (immunity cells) reaches 250. Normal people have between 800 and 1200 CD4 cells per blood count.

March 31, 2009 7:22 PM  
Anonymous Anonymous said...

If normal people have between 800 and 1200 CD4 cells, then how many do homosexuals have?

March 31, 2009 11:36 PM  
Anonymous Robert said...

"If normal people have between 800 and 1200 CD4 cells, then how many do homosexuals have?"

It's like tapping that tendon below the knee, the leg jerks automatically. I think he can't help it. It's not a choice for him.


April 01, 2009 8:14 AM  
Blogger AJ said...

I wanted to thank you for pointing this article out. I think I had a knee-jerk "that's b.s." reaction to the Pope's words, so it was good to get the perspective of an actual scientist who is more familiar with the HIV/AIDS epidemic in Africa.

I've heard other criticisms of aid organizations unsuccessfully trying to impose "Western" solutions on African populations, and perhaps the push for condom use is an example of that phenomenon.

The author seems to indicate that getting people to embrace sexual monogamy is possible, although I wonder if a cultural shift like that is more realistic than getting everyone to use condoms.

April 01, 2009 10:29 AM  
Anonymous Anonymous said...

"The author seems to indicate that getting people to embrace sexual monogamy is possible, although I wonder if a cultural shift like that is more realistic than getting everyone to use condoms."

It's just as possible here in America, AJ, and more likely to succeed.

April 01, 2009 11:18 AM  
Anonymous No April Fool said...

That's right!

Sexual monogamy is such a *success* here that there are no divorces due to infidelity ever in the United States of America, no cultural shift necessary.

April 01, 2009 8:38 PM  
Blogger Orin Ryssman said...

Jim writes,

If everybody was faithful to one partner, even without condoms the epidemic would shrink to nearly nothing. This anthropologist is saying that's what has to happen in Africa. How do you get that to happen? He doesn't explain that part of it.

LOL...really now, how can you, being such a well educated and seemingly intelligent person, ask such a question? The answer is that the best prophylactic is sexual continence, self-control, and...GASP! (dare I say it?...oh heck, I will throw caution to the wind) discipline.

Sigh...I know, I know...that is so unrealistic to expect since we are just evolved members of the animal kingdom.

Well, those that survive are those on the continent of Africa that can see the "writing on the wall" and understand that their very survival depends upon them exercising self-control. And in an intuitive way they can understand that while pain is a part of life, suffering...that is optional.

And all of this reminds me of the lone protester I saw as I left Sunday Mass almost two weeks ago. This person had a sign that said the Pope should sell all of the Vatican art and buy condoms for those in Africa. Now how silly is that???...suggesting that the guardian of a priceless collection of irreplaceable art sell it for something as disposable as a condom. Fortunately Pope Benedict XVI is as wise as he is smart...

April 03, 2009 1:15 AM  
Anonymous Anonymous said...

"really now, how can you, being such a well educated and seemingly intelligent person, ask such a question? The answer is that the best prophylactic is sexual continence, self-control, and...GASP! (dare I say it?...oh heck, I will throw caution to the wind) discipline."

Thanks for the input, Orin. I would only add that societal standards play an indispensable role.

That's why comp sex ed, as currently taught, undermines the health of young people.

April 03, 2009 9:29 AM  
Anonymous Aunt Bea said...

For sex ed to be effective, it should teach these facts. Thank goodness MCPS has managed to get most of this information included in its curriculum.

The CDC reports:

HIV Infection
Consistent and correct use of latex condoms is highly effective in preventing sexual transmission of HIV, the virus that causes AIDS.

Other STDs and Associated Conditions
Consistent and correct use of latex condoms reduces the risk for many STDs that are transmitted by genital fluids (STDs such as chlamydia, gonorrhea, and trichomoniasis). Consistent and correct use of latex condoms reduces the risk for genital ulcer diseases, such as genital herpes, syphilis, and chancroid, only when the infected area or site of potential exposure is protected. Consistent and correct use of latex condoms may reduce the risk for genital human papillomavirus (HPV) infection and HPV-associated diseases (e.g., genital warts and cervical cancer).

To achieve maximum protection by using condoms, they must be used consistently and correctly.

The failure of condoms to protect against STD/HIV transmission usually results from inconsistent or incorrect use, rather than product failure.
-Inconsistent or nonuse can lead to STD acquisition because transmission can occur with a single sex act with an infected partner.
-Incorrect use diminishes the protective effect of condoms by leading to condom breakage, slippage, or leakage. Incorrect use more commonly entails a failure to use condoms throughout the entire sex act, from start (of sexual contact) to finish (after ejaculation).

How to Use a Condom Consistently and Correctly:
-Use a new condom for every act of vaginal, anal and oral sex—throughout the entire sex act (from start to finish).
-Before any genital contact, put the condom on the tip of the erect penis with the rolled side out.
-If the condom does not have a reservoir tip, pinch the tip enough to leave a half-inch space for semen to collect. Holding the tip, unroll the condom all the way to the base of the erect penis.
-After ejaculation and before the penis gets soft, grip the rim of the condom and carefully withdraw. Then gently pull the condom off the penis, making sure that semen doesn't spill out.
-Wrap the condom in a tissue and throw it in the trash where others won't handle it.
-If you feel the condom break at any point during sexual activity, stop immediately, withdraw, remove the broken condom, and put on a new condom.
-Ensure that adequate lubrication is used during vaginal and anal sex, which might require water-based lubricants such as K-Y JellyTM, AstroglideTM, AquaLubeTM, and glycerin. Oil-based lubricants (e.g., petroleum jelly, shortening, mineral oil, massage oils, body lotions, and cooking oil) should not be used because they can weaken latex, causing breakage.

April 04, 2009 9:30 AM  
Anonymous Aunt Bea said...

Condoms not only prevent STDs, they also prevent unplanned pregnancy. But they must be used correctly and consistently for every instance of sexual contact to be effective.

"WASHINGTON (April 3) - Levi Johnston says ex-fiancee Bristol Palin, daughter of Alaska Gov. Sarah Palin, allows him to visit their 3-month-old son but won't let him take the baby out.

In an interview to air Monday with talk show host Tyra Banks, Johnston, 19, said he and 18-year-old Bristol don't always get along.

"Some days we can have regular conversations without fighting," Johnston said. "Most of the times, I don't know what's wrong with her. She's in a pretty bad mood, she's short, she doesn't want me around, I don't think. She says that I can come see the baby and that kind of thing, but won't let me take him anywhere."

The two are the parents of an infant son, Tripp, born on Dec. 27.

Palin family spokeswoman Meghan Stapleton said Bristol Palin was unaware Johnston would be appearing on "The Tyra Banks Show," along with his mother, Sherry, and sister, Mercede.

"We're disappointed that Levi and his family, in a quest for fame, attention and fortune, are engaging in flat-out lies, gross exaggeration, and even distortion of their relationship," Stapleton said in a statement Friday.

Stapleton has said Bristol Palin isn't preventing anyone from seeing the baby, and that Johnston sees his son "whenever he wants, the family sees the baby whenever they want."

Johnston told The Associated Press on March 11 that the couple had broken off their engagement. He has said they needed time to grow up before following through on marriage plans.

In the interview with Banks, Johnston said the Alaska governor probably knew he and Bristol were having sex. "Moms are pretty smart," he said.

Sarah Palin announced her daughter's pregnancy on Sept. 1, days after Sen. John McCain picked her to be his Republican vice presidential running mate. Johnston later appeared at the Republican National Convention with the Palins.

Johnston told Banks he went to the convention at Bristol's request, but he wasn't thrilled to attend it. "I felt out of place," he said.

Asked whom he'd vote for in 2012 if the choice were President Barack Obama or the Alaska governor, he said: "I still think I'm going to have to vote for Sarah Palin."

April 04, 2009 1:58 PM  
Anonymous Anonymous said...

"Condoms not only prevent STDs, they also prevent unplanned pregnancy. But they must be used correctly and consistently for every instance of sexual contact to be effective."

Abstinence outside of marriage works just as well if "used correctly and consistently for every instance of sexual contact."

April 06, 2009 10:17 AM  

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