Searching for Solutions to AIDS. 27/6/10
The benefit obtained through the intervention of something designed to reduce risk can be offset by people becoming careless with their behavior.
Rome(Zenit.org).- The Catholic Church is regularly pilloried for its refusal to back the use of condoms in fighting the spread of HIV and AIDS. This nonacceptance is not only sound moral teaching, but it also has solid scientific foundations.
That’s the thesis of a book just published by the National Catholic Bioethics Center, based in Philadelphia. In "Affirming Love, Avoiding AIDS: What Africa Can Teach the West," Matthew Hanley and Jokin de Irala take a look at why efforts to stop the spread of the HIV virus in Africa have had so little success and how this is linked to the reliance on condoms.
Hanley was the HIV/AIDS technical advisor for Catholic Relief Services until 2008 and is specialized in HIV prevention. De Irala is deputy director of the Department of Preventative Medicine and Public Health at the University of Navarra in Spain.
The authors start by noting that almost all the Western institutions active in this area share the firm opinion that risk reduction strategies, such as the promotion of condom use, must be a priority. What they term the "AIDS Establishment" has concentrated on technical means rather than on behavioral change.
The exception to this was the change in policy by the United States to adopt an ABC strategy following the success of Uganda in using this approach to deal with AIDS. The "A" stands for abstinence, "B" for be faithful, and "C" for condom use.
It's the first two parts to this strategy that are crucial, the book argues. In fact, wherever there has been falling HIV rates in Africa, it has been the result of fundamental changes in sexual behavior.
Seeking to modify how people behave is not only more successful but, the authors add, is a common-sense return to medicine's principle of primary prevention. Prevention of HIV transmission is urgent in parts of the world such as Africa, where there are serious difficulties in providing adequate medical treatment.
Hanley and de Irala make a comparison with the use of tobacco. Maybe once it seemed unrealistic to change a situation where 75% of people smoked, but public health authorities embarked on campaigns to change such lifestyle choices, with success.
Why is it then, they ask, that when it comes to tobacco, cholesterol, sedentary lifestyles, and excessive consumption of alcohol, authorities consider them to be behaviors that require change, but sexual behavior associated with disease is not?
One problem associated with reliance on a risk reduction approach that looks to technical fixes instead of changes in behavior is that it can lead to what is called risk compensation. This means that the benefit obtained through the intervention of something designed to reduce risk can be offset by people becoming careless with their behavior.
The authors point out that just as a seatbelt is no guarantee of safety if someone thinks they can drive faster than normal because they are protected by it, so too condom promotion can lead to people thinking it is safe to engage in greater sexual activity.
This is particularly relevant in Africa, where studies show that when a significant number of people are engaged in concurrent sexual relationships the chances of infection are much higher compared to communities where people reduce multiple partnerships. A decline in multiple sexual partnerships is crucial to bringing about a decline in HIV rates, the authors affirm.
The best example of this was in Uganda, where HIV infection rates dropped from 15% in 1991 to 5% in 2001. What brought about this radical change was a major shift in sexual behavior, the book notes.
This wholly rational decision to avoid the risk of a fatal and traumatic disease by altering behavior ultimately spared millions of lives,” the authors add.
While the rate of condom use in Uganda was similar to that of Zambia, Kenya and Malawi, the number of non-regularpartners in Uganda sharply decreased. And while the HIV rate went down in Uganda it did not decrease in the other countries.
One of the reasons behind the success in modifying conduct in Uganda, the authors point out, was the work of Catholic nuns and doctors. An Anglican bishop and a Catholic bishop were also among the first presidents of the country AIDS commission.
Unfortunately in recent years the AIDS establishment has gained influence in Uganda and the emphasis has shifted toward promoting the use of condoms. This has been accompanied by an increase in HIV transmission.
Kenya, Thailand and Haiti are additional countries that the authors refer to in citing evidence from studies that show how behavioral change leads to a reduction in the rates of HIV transmission.
By contrast, in South Africa, where promotion of condom use has been the main priority, the persistently high rates of multiple partnerships has helped to maintain the level of HIV infections at what the authors describe as an alarmingly high incidence
The idea of abstinence does not sit easily with contemporary culture, but Hanley and de Irala point out that while fidelity appears to have been the most important factor in Africa success, abstinence is also important.
Abstinence influences future behavior, they maintain, and the earlier a person initiates sexual activity the more lifetime sexual partners that person is likely to have, thus increasing the risk of contracting HIV.
The book refers to a study carried out by the United States Agency for International Development which looked at variables associated with HIV prevalence in Benin, Cameroon, Keyna and Zambia.
It concluded that the only factors associated with lower HIV prevalence were lower lifetime number of partners (fidelity), an older age of sexual debut (abstinence), and male circumcision. The study also found that socio-economic status and condoms use were not associated with lower HIV prevalence.
In spite of this and other evidence provided in the book the authors point out that the documents on AIDS published by the United Nations describe the use of condoms as the most effective technology for AIDS prevention.
Condoms may well be the most effective technology; for reducing these infections, the authors admit, but the are certainly not the most effective prevention measure.
While this debate over how to deal with HIV is often cast in scientific language Hanley and de Irala maintain that it is more of a contrast between two moral and philosophical approaches to human sexuality. On one side there is the Judeo-Christian tradition, which sees sexuality as within the institution of marriage. This tradition recognized moral boundaries and the practice of self-restraint as a way to achieve human fulfillment.
On the other side is the modern Western culture that exalts absolute freedom in the pursuit of pleasure. This explains why this conceptual approach looks for technical means to deal with the undesirable consequences of sexual activity.
On June 9 Archbishop Celestino Milgiore, the permanent observer of the Holy See at the United Nations addressed the General Assembly on the issue of HIV/AIDS.
If AIDS is to be combated by realistically facing its deeper causes and the sick are to be given the loving care they need, we need to provide people with more than knowledge, ability, technical competence and tools, he said.
He recommended that more attention and resources be dedicated to supporting a value-based approach grounded in the human dimension of sexuality.
What we need, he continued, is an honest evaluation of past approaches that may have been based more on ideology than on science and values, and for determined action that respects human dignity and promotes the integral development of each and every person and of all society.
An appeal for all to cast aside prejudices and pre-conceived notions when it comes to dealing with this grave problem.