The ban that kills: the Vatican's allegations about condoms deny scientific fact and cost some people their lives.

THE MOST RECENT STATISTICS ON THE SPREAD OF HIV/AIDS make it more urgent than ever for the institutional church to reconsider its stance on condoms. While there are some positive signs of movement beyond the walls of the Vatican, a recent paper by Cardinal Alfonso Lopez Trujillo (president of the Pontifical Council for the family) has shown that the Vatican remains intransigent and insular on this subject.

This is in contrast to indications of a renewed consideration being given to the "principle of double effect" by some in the church hierarchy. This principle notes that condoms have two functions: to prevent conception and to prevent disease transmission. Although the Vatican has banned the use of the condom as a method of contraception, to use a condom to prevent the transmission of a fatal disease could be seen as a "lesser evil."

Among the recent dissenters from the Vatican's hard-line view, Belgian Cardinal Godfried Danneels spoke out in early 2004, saying that there are some circumstances in which condoms should be used. Danneels stated that if someone is HIV-positive and does not wish to abstain from sex, they should use a condom to prevent infecting others, otherwise they will be breaking the commandment, "Thou shalt not kill." As a recent BBC Panorama program noted, in Uganda it has been suggested that people who refuse to use a condom (on religious grounds) with their husband or wife who they know to be HIV-infected may be regarded as martyrs. ("Can condoms kill?" June 27, 2004.) This is morally unacceptable. More recently, the UK's Cardinal Cormac Murphy-O'Connor spoke out in support of Cardinal Danneel's position on the use of condoms and the UK-based Catholic overseas development charity CAFOD also endorsed their use within a broader individual-based risk reduction strategy. (For more on this, see "The Good Shepherds Awards," these pages.)

THE RAGING HIV/AIDS PANDEMIC 

When considering the Vatican's position on condoms, it is important to bear in mind the stark reality, of the current AIDS epidemic. The Joint United Nations Programme on HIV/AIDS (UNAIDS) released figures on World AIDS Day estimating that there are between 36 and 44 million people infected with HIV/AIDS worldwide and about 14,000 new infections daily, mostly through heterosexual sex. Just under two-thirds of those living with HIV/AIDS are in Sub-Saharan Africa. Levels of HIV vary widely across the African subcontinent, with the prevalence of infection among adults aged 25-49 exceeding 35% in Swaziland and Botswana.

The high levels of HIV infection are driven by many factors including poverty, conflict, mobility and gender inequality. Women are now an increasing proportion of HIV infections. Societal, economic and biological gender inequalities--such as men choosing younger sexual partners and women often Facing sexual violence and coercion--result in women being at increased risk of HIV infection compared to men. This is particularly apparent among young women in Sub-Saharan Africa where 57% of all people infected are women and girls, and more than three-quarters of young people infected are female.

There are also rapidly growing epidemics in parts of Asia and Eastern Europe. India is second only to South Africa in having the highest number of people living with HIV/AIDS. In many countries where HIV prevalence is fairly low, HIV infection is primarily concentrated in the groups most vulnerable to infection such as sex workers and injecting drug users. For example, data from sites in Vietnam, Indonesia and China indicate that 31-64% of injecting drug users and 7-16% of sex workers are HIV-infected. As the epidemic progresses, the sexual networks beyond these encounters also put regular partners at risk. Indeed, in some settings a large proportion of HIV infections now occur in regular partnerships. For example, in Cambodia in 2002, 60% of infections were between spouses where one was previously at risk through buying or selling sex. Likewise, more than 20% of infections in Honduras (2002), Kenya (1998) and Russia (2002) are from non-casual sex with a partner at risk. Several epidemiological studies find marriage to be the main risk factor of infection for women. For example, a study of married monogamous women in India concluded that it is likely that these women were being infected by their spouses. Despite this widespread and growing risk, few people around the globe know their HIV status, and many are not even aware that they are at risk, or lack knowledge of how to protect themselves from HIV.

CONDOMS: A CORNERSTONE OF HIV PREVENTION

The condom is a life-saving device: it is highly effective in preventing HIV transmission if used correctly and consistently, and is the best current method of HIV prevention for those who are sexually active and at risk. A review from the US National Institutes for Health concluded that condoms are protective against HIV infection, reducing the annual rate of HIV infection in sero-discordant couples (where only one partner is infected and risk of infection to the other is high) by 85% when used consistently. (National Institutes of Health, "Workshop summary: scientific evidence on condom effectiveness for sexually transmitted disease (STD) prevention," July, 2001) The efficacy of the condom per sex act will be even higher than this annual rate.

There is growing evidence that HIV prevention interventions can achieve substantial increases in levels of condom use in commercial and casual sex partnerships. Surveys of sex workers in Asia generally find that many--often over 70%--used condoms when they last had sex with a client. Sex workers in SubSaharan Africa can also attain high levels of consistent condom use with their clients. In some cases this rise in condom use clearly mirrors the declining levels of HIV infection. Figure 1 shows that the HIV prevalence among sex workers who were first time attendees at a STI/AIDS testing clinic decreased as the consistency of condom use increased.

[FIGURE 1 OMITTED]

SELECTIVE INTERPRETATION OF DATA

The evidence on the condom's effectiveness is turned the other way round by Cardinal Trujillo who, instead of highlighting the protection provided, focuses on condoms' (annual) 15% failure rate in order to dissuade people from using them. Yet, perfection is not needed for a method to be immensely effective. Much in real life is not perfect--but the condom has a high effectiveness rate and the blunt fact is that, whether you see the glass as 85% full or 15% empty, if a person is going to have sex it is much better to use a condom than not to use one. Of course, some people may be in a position to choose and be able to remain abstinent until finding a lifetime partner who has also remained abstinent (and both have avoided HIV infection). However, banning condoms outright offers no possibility of protection for those who cannot or do not choose this lifestyle.

Cardinal Trujillo supports his argument that condoms do not protect against HIV by citing examples where HIV/AIDS cases increased as the number of condoms distributed also increased, and argues that as there is a much lower HIV prevalence in the Philippines (where there is strong opposition to the condom program by the church and a number of government leaders) than in Thailand (where a 100% condom use program was implemented for commercial sex), then condoms must not be effective. This is a selective interpretation of the data. We would hope that as HIV prevalence and general awareness of HIV/AIDS increase, condom demand, distribution and use would also increase. The HIV prevalence in a population can only decrease as people die or as new uninfected people move into or are born into that population. This means that there may be a time-delay between condom use increasing and the effects of this on HIV prevalence being observed. Broad-brush comparisons between countries, such as Cardinal Trujillo made, are misleading. HIV epidemics are at different stages and of different types in different countries, and we should not draw over-simplistic conclusions about the reasons for this. Some suggest that the Philippines is on the verge of a HIV epidemic, while Thailand had to tackle its HIV epidemic much earlier. In fact, a major epidemic was probably averted through Thailand's strong provision of condoms for commercial sex (starting in 1990).

Levels of awareness and correct knowledge of condoms, and their use, are also likely impeded by the Vatican perpetuating untruthful anti-condom myths. (See, for example, the previously cited Panorama program and another broadcast October 12, 2003, called "Sex and the Holy City" and Katha Pollitt's article, "Is the Pope crazy?" in the Winter 2003-4 issue of Conscience.) As Cardinal Godfried Danneels said, when rebuking Cardinal Lopez Trujillo for his statements about condoms failing to protect against HIV, "it does not benefit a cardinal to deal with the virtue [scientific integrity] of a product." It is irresponsible of the Vatican to dismiss or misrepresent this scientific evidence that has been produced by leading international and scientific agencies, which clearly demonstrates that condoms, when used correctly and consistently, are highly effective at preventing HIV transmission.

INFLUENCE OF THE CHURCH'S OBJECTIONS TO CONDOMS

There has been criticism that HIV prevention has traditionally focused extensively on condoms. Cardinal Trujillo seems to hold the view that many who promote condoms do so in a vacuum--devoid of all other options. Yet the popular AIDS education messages of recent times promote first abstinence then faithfulness or partner reduction, and then condoms. The enormity and complexity of the HIV epidemic means there are no easy solutions. The general consensus is, however, that condoms do have an important part to play in a comprehensive response to the HIV epidemic.

When somebody holding strong socially or religiously conservative views also wields influence over national legislation, they can control the channeling of funds away from certain HIV/AIDS prevention programs, for example those that promote and distribute condoms. In addition, if some people's lifestyles, such as sex workers and homosexuals, are deemed to be illegal, it not only increases the stigma and discrimination these groups face but may also drive them away from accessible AIDS education and prevention services.

Particularly in settings where Catholicism is the predominant religion, the institutional church may limit the extent to which people are able to access condoms and also influence whether or not they are used. Indeed, the Roman Catholic church's "disproportionate impact on world opinion and laws around the globe on sexual matters" was highlighted by Mary Hunt in Conscience in Autumn 2003. The prominent concerns in the AIDS prevention arena are the Vatican's opposition to condoms and its ability to sway national and international policies that subsequently impact on HIV/AIDS prevention strategies and services. Examples range from Brazil in the late 1980s when any AIDS prevention material mentioning condoms was vetoed and more recently with the banning of artificial contraception in Manila. In May 2004, Human Rights Watch published a report stating that the government of the Philippines "impedes access to condoms," crippling the work of HIV/AIDS service providers. The reason given by the Philippine Department of Health for refusing to promote condoms was "fear of offending conservative Catholics."

PROMOTING CONDOMS TO PREVENT DEATH

Polls consistently show that most Catholics disagree with the hierarchy's ban on condoms. Yet the same hierarchy that controls 100,000 hospitals and 200,000 other social service agencies worldwide ban both education about and the provision of condoms in their institutions. This attitude towards condoms is in sad contrast to the important contribution the church makes to the provision of AIDS care. Catholic organizations provide some 25% of AIDS care worldwide, making the Catholic church the largest institution in the world providing direct AIDS care. Ironically, the Vatican undermines the vital work of these many Catholics with its opposition to condom use.

Although condoms provide high levels of protection against HIV, their levels of use could be higher if the problems of supply, access and affordability were more fully tackled. One study (published in the British Medical Journal in 2000 estimated that an average of five condoms per man was distributed in Sub-Saharan Africa in 1999--excessively low for a region ravaged by the HIV epidemic. The limited condom availability is due to many factors, including the failure of HIV prevention programs to expand their activities to a large scale--the 2003 "UNAIDS Progress Report on the Global Response to the HIV/AIDS Epidemic" concluded that only a fraction of people at risk of contracting HIV have meaningful access to basic prevention services.

Since it is unlikely that an AIDS vaccine will be developed in the next decade, it is important that significant investment and commitment is made in supplying and promoting condoms.

The institutional church has given undue attention to condoms as a method of preventing life and so has opposed them--limiting access to condoms and dissuading people from using them. Recently, Cardinal Trujillo has furthered this by instituting a fear of condom failure. While condoms are not the best product for preventing pregnancy, they are the only product available to sexually active people to prevent HIV infection, and are highly efficacious. For this reason, and given the raging HIV epidemic that is killing millions worldwide, the church hierarchy needs to acknowledge the high efficacy of condoms and revisit the "principle of double effect" to view condoms primarily as a method to prevent HIV infection and death. The large contribution the church makes to AIDS care is indicative of its potential to also impact strongly in the field of HIV prevention. It is illogical and inconsistent for the hierarchy to work to care for those infected by HIV while restricting the ability of uninfected people to protect themselves from the virus. A responsible and compassionate church leadership would be investing energy not only into providing care to those with AIDS but also in actively distributing and promoting condoms within a comprehensive strategy to help prevent HIV infection and save lives.

The Good Shepherds Awards

On World AIDS Day, December 1, 2004, the Condoms4Life campaign, a project of Catholics for a Free Choice, awarded four Good Shepherd Awards to Catholic bishops for their positions on condom use to prevent the spread of HIV/AIDS. Good Shepherds will receive a small sculpture honoring their contributions to HIV prevention efforts.

"In 2004, the Catholic church has been both a positive and negative influence on stemming the pandemic and promoting a responsible policy on HIV/AIDS prevention," said Frances Kissling, president of Catholics for a Free Choice, which initiated the Condoms4Life campaign. "Condoms4Life issues these awards to encourage those bishops who demonstrate sanity, compassion and justice when confronted with HIV/AIDS. While focusing on progress within the church, we also want to call attention to those bishops whose actions are harmful to those at risk of HIV and AIDS."

Condoms4Life urges the Vatican to lift its ban on condoms as a moral and humanitarian matter. By the end of 2003, there were an estimated 37.8 million people worldwide living with HIV/AIDS, including the almost 5 million new people who acquired HIV. We ask bishops opposed to the use of condoms to clarify that their objections to condoms as a means of HIV/AIDS prevention are ecclesiastical, not scientific. Finally, we call upon the bishops and clergy to repudiate the incorrect information that has been circulated by officials of the Catholic church, and we strongly encourage all to be scrupulously honest in describing the effectiveness of condoms in the future.

The Condoms4Life campaign is a worldwide public education effort to raise public awareness about the devastating effect of the bishops' ban on condoms. Launched on World AIDS Day 2001, the first phase of the campaign included billboards and ads in the US, Mexico, the Philippines, South Africa, Kenya, Chile and Zimbabwe to change the Vatican's policy and challenge its aggressive lobbying against availability and access to condoms in areas of the world most at risk. The ads are available online at www.Condoms4Life.org. Condoms4Life has also developed Sex in the HIV/AIDS Era: A Guide for Catholics to assist at-risk Catholics who are struggling with questions around faith and conscience, sexuality and the use of condoms for HIV/AIDS prevention (available at http://www.condoms4life.org/ facts/index.htm).

Good Shepherd Award: Cardinal Godfried Danneels

In January, this Belgian bishop articulated on Dutch public television a highly nuanced position on AIDS prevention that accepts the church's position on abstinence but acknowledged that if sexual relations are going to occur between people who are at risk, condoms should be used. "When an HIV-positive person says to his partner, 'I want to have sexual relations,' he must use a condom," said the cardinal. "Morally, it cannot be judged on the same level as when a condom is used to reduce the number of births."

Good Shepherd Award: Cardinal Cormac Murphy-O'Connor

In July, Cardinal Murphy-O'Connor of Westminster, England, publicly agreed with Cardinal Danneels in an interview with the Independent of London. "While we can say that, objectively, the use of condoms is wrong, there are places where it might be licit, or allowable, as when there's a danger of intercourse leading to death. It would be wrong to take a special case and make it a universal law."

Good Shepherd Award: Bishop Kevin Dowling 

In March 2004, Bishop Dowling of Rustenburg, South Africa, continued his leadership on the issue of condom use when he addressed an audience of 200 at Boston College in Massachusetts. "Abstinence before marriage and faithfulness to a single partner within a stable marriage--obviously, those are key to good living [and] to avoid infection. However, the church ministers in the real world ... the church should give people [all] the options, one of which is to use a condom, not as a contraceptive, but to prevent transmission of a death-dealing virus," he told the crowd. Using the 1968 papal encyclical condemning artificial contraception but supporting the use of oral contraceptives to control menstrual bleeding, the bishop argued that condoms play a similar medical role in stemming the spread of AIDS. The church prohibits the condom as contraception, but when used to protect against AIDS, "it's not being used as a contraceptive. The basic principle is there to be at least discussed. People end up in relationships for a variety of reasons. Their journey in life takes them to decisions about sexuality for many reasons. I believe the church should be fundamentally experienced by people as a revelation of the compassionate, nonjudging God that gives people space to go through a range of experiences in the quest for basic human dignity."

Good Shepherd Award: Commission for health of the Catholic Bishops' Conference of India 

In September, the Catholic church in India began to construct its first policy on HIV/AIDS prevention. While the institutional church has historically been hostile to condom use and even spread misinformation to deter people from using condoms, the bishops of India are developing a policy to provide people with information about condoms. According to lames Veliath, coordinator of the CBCI program on HIV/AIDS in the northern region, "The church will not be promoting or propagating the use of condoms. We will, however, provide all information about it. In case a couple wants to use it, we would suggest they speak to their pastor and then take a decision based on what their conscience says."

Condoms4Life acknowledges the courage of the 11 bishops who participated in the development of the HIV/AIDS Policy of the Catholic church in India.

ACKNOWLEDGEMENTS

The views expressed are those of the authors and cannot be taken to reflect the official opinion of the London School of Hygiene and Tropical Medicine. Full references for the statistics cited in this article are available from the first author, [e-mail].

ANNA FOSS, PETER VICKERMAN and CHARLOTTE WATTS are members of the HIV Tools Research Group, a multidisciplinary academic research group based in the Health Policy Unit at the London School of Hygiene & Tropical Medicine (UK) conducting HIV/AIDS-related research in resource-poor settings, www.hivtools.lshtm.ac.uk.