A public-health culture war is raging. As it becomes clear that condoms are not the cure-all to AIDS in Africa, the AIDS establishment is battling to discredit a less condom-dependent approach to preventing the spread of HIV.
New York Times columnist Nicholas Kristof recently wrote a piece, "The Secret War on Condoms," accusing the Bush administration of waging jihad against condom use.
Kristof reports that "the U.S. is now donating only 300 million condoms annually, down from about 800 million at the end of the first President Bush's term." He fails to mention that the number of donated condoms fluctuated during the past decade, and in some years during the Clinton administration was lower than 300 million. He writes that "the average man in Botswana gets less than one condom per year from international donors" -- suggesting that backward Bushies are denying Botswanans their very means of survival. Actually, Botswana is a relatively rich African country. It doesn't need donated condoms.
The essential fact that the AIDS establishment wants to ignore is this: The countries with the highest condom-availability and reported user rates in Africa -- Botswana and Zimbabwe -- also have among the highest HIV-infection rates. This finding runs exactly counter to Condom Orthodoxy. How to explain it?
In Africa, international family-planning groups market condoms with names like Shield and Protector, in Madison Avenue-style campaigns that lose all nuance. Yes, you're far better off using a condom than not. But they can slip, break or leak, and they can be used improperly or, worse, inconsistently.
A meta-analysis of all published literature on condom effectiveness in 2002 found that consistent condom use had about an 80 percent success rate in preventing the virus from spreading from one partner to another. But this is with consistent condom usage. Much of the actual usage in Africa is inconsistent.
African men might use condoms with prostitutes (it's important that they do), but are reluctant to use condoms with spouses or regular partners. People in Africa get married to have kids, so condom use seems to run counter to the purpose of marriage. Condom use also raises the uncomfortable possibility of a spouse or partner having been unfaithful.
"We know that many men and a large proportion of women simply do not use condoms no matter how much education and social marketing they have been exposed to," writes Edward C. Green of the Harvard School of Public Health in his forthcoming book, "Rethinking AIDS." "Demand for condoms seems to have already peaked in Africa, at well below the levels at which they can make a significant difference."
In the United States, HIV infections have basically been confined to populations that engage in high-risk behaviors, making it easier to check the virus with condoms. In Africa, HIV has spread to the general population, making it difficult to head off infections with condoms alone. They will never be used uniformly enough -- or, arguably, be effective enough -- to choke off such a pervasive epidemic.
Part of the answer in Africa is urging people to have fewer sexual partners. This behavior-based approach accounted for most of Uganda's nearly miraculous reduction in infection rates in the early 1990s, according to Green and other researchers. But even Uganda is beginning to lose ground. Under pressure from Western donors, its anti-AIDS program now has less emphasis on abstinence and faithfulness, and more on condoms. Infection rates have begun to creep up.
None of this is to suggest that condoms aren't useful in fighting AIDS.
"It's very important that people at high risk have access to condoms," says Green, an advocate of a balanced approach. It was, for instance, the promotion of condoms in Thailand's sex industry that dramatically reduced HIV infection rates there.
But neither is the condom a magic totem. It has its flaws and limits, and will not alone solve the AIDS crisis in Africa. The faster the AIDS establishment gets the courage to admit it, the better.