Condoms and HIV/AIDS in the developing world

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Durandal
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Condoms and HIV/AIDS in the developing world

Postby Durandal » Fri Mar 20, 2009 10:15 pm UTC

I'm sure all of you have heard the Pope's recent comments on condoms (discuss that here).

I mean, condoms are always a good thing. They're pretty much the only measures that will stop the transmission of STIs during intercourse.

Which is true, but of course the problem of HIV/AIDS is not so simple that we can just throw condoms at it. Over here, condoms are used as a precaution; a just-in-case type deal. In developing countries though, they're an absolute necessity. If one is infected with HIV and having intercourse with someone who isn't, condoms HAVE to work. But mostly due to human error, they don't. At least not all the time. (The quoted failure rate is 10% [source])

So to keep from rambling, I'll just put up an argument for you to discuss, because I'd like to see both sides of this pro-condom vs. anti-condom debate represented.
Thesis:
Condoms may not have a net positive effect on the HIV/AIDS problem, due to inspiring confidence that there is no risk of infection when used and therefore causing those infected with HIV/AIDS to have more sex than they would otherwise.


My personal thoughts on the matter are that condoms are very much a necessity in the fight against HIV/AIDS in Africa, but to call them a solution (and more specifically, to market them as such) is a grave error. I believe it's Uganda that decreased the seriousness of its HIV/AIDS epidemic through the ABC process, which goes Abstinence, Be faithful to your partner and, if that fails, use Condoms.

Now, the mistake that most people make here is equating this whole debate to the one about abstinence-only sex education. While there are some parallels, the differences are great and thus one should not be misrepresented as the other.

The HIV/AIDS problem is not one that will be solved for a long time, barring the invention of a vaccine. With the combination of abstinence, faithfulness and condoms however, hopefully it will slowly decrease to a manageable level.

Edited.

This thread isn't about the Pope, or his views, or that other thread. So don't continue to talk about the Pope. I will tolerate this topic duplication provided that it fulfills all the normal SB-worthy criteria and it does not appear that someone is trying to restart the exact same discussion with hopes of a more favorable outcome.

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Re: Condoms and HIV/AIDS in the developing world

Postby Azrael » Fri Mar 20, 2009 10:35 pm UTC

If you assume that advocating the use of condoms will increase the number of people having sex, then it logically follows that those people will be using condoms. Continuing with the cited 90% success rate, 10% of those newly sexually active persons (Call it Group A) would be at risk for HIV.

So the numerical argument supporting your hypothesis would be to say that the size of Group A is larger than the size of Group B, the number of people who's risk is mitigated by using condoms. The condom success rate defines Group B to be 90% of the number of already sexually active persons who start using condoms.

You would need to have at least 9 times as many people start having sex as people who would start using condoms before a negative effect was seen.

That seems unlikely.

Example: Assume 1000 people start having sex because of increased condom availability. So 100 of them are at risk for contracting HIV. I'd only need 111 people to start using condoms to offset that effect. Even factoring in that some percentage of those people enticed into having sex because of condoms might someday stop using them, the numbers are still heavily skewed towards resulting in a net benefit.

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Re: Condoms and HIV/AIDS in the developing world

Postby floodslayer » Sat Mar 21, 2009 12:41 am UTC

Azrael wrote:You would need to have at least 9 times as many people start having sex as people who would start using condoms before a negative effect was seen.

That seems unlikely.


I'm inclined to agree. I don't really see that much convincing evidence that lack of access to condoms acts as a deterrent. It's important to remember that in developing nations, education about the nature and spread of HIV is one of the primary challenges. If people aren't well educated about the threat of AIDS and how it's spread, then lack of access to condoms isn't likely to be a deterrent. I think the issue is often viewed in that way simply because in western societies the debate about condoms in schools usually goes along those lines. Kids in the US know about STDs, and if they can't get condoms, some of them will choose not to have sex. In a society where this knowledge is less prevalent, I think it's not likely to be (as great) a factor.

However, I do think the TC has a valid point in that looking to condoms as a solution is a little short sighted. People in general, and politicians especially, have a tenancy to make these issues single faceted. Some people will see access to prophylactics in Africa and say "good, problem solved". Testing and treatment are also going to be important, as well as education, and an emphasis on monogamy. But, with abstinence and monogamy both being what they are in the west these days, I think it's hard for us to push either of these as a catch all solution.

In short, this issue, like most problems we face in the world, is a complex one. The primary danger is boiling this rather complex issue into too simple terms.

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Re: Condoms and HIV/AIDS in the developing world

Postby Dream » Sat Mar 21, 2009 1:58 am UTC

Azrael wrote:You would need to have at least 9 times as many people start having sex as people who would start using condoms before a negative effect was seen.


This does not take into account the potential increase in promiscuity of these people. More partners, and partners from higher risk groups would mean that raw numbers about failure rates are insufficient data. The 90% success rate could well make men more likely to use prostitutes, engage in infidelity or just sleep around. For a high enough infection rate, that would be massively risky even with condoms, and as such condoms couldn't be said to be helping in that situation. You'd need condoms along with abstinence-from-stupid-sex for that. And abstinence-from-stupid-sex is basically teaching people to be faithful to their partners.

I think that if the rate of infection in a community is high enough, condom use cannot be honestly argued to be a solution. It would only create a false sense of security. Considering how high infection rates are in many parts of Africa, and how those rates must be higher among certain communities within those countries, I'd say there probably is a place for abstinence in combating HIV.
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Re: Condoms and HIV/AIDS in the developing world

Postby Azrael » Sat Mar 21, 2009 2:36 pm UTC

Hey guys, guess where all those posts went.

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Re: Condoms and HIV/AIDS in the developing world

Postby Azrael » Sat Mar 21, 2009 2:46 pm UTC

Dream wrote:This does not take into account the potential increase in promiscuity of these people. More partners, and partners from higher risk groups would mean that raw numbers about failure rates are insufficient data. The 90% success rate could well make men more likely to use prostitutes, engage in infidelity or just sleep around. For a high enough infection rate, that would be massively risky even with condoms, and as such condoms couldn't be said to be helping in that situation. You'd need condoms along with abstinence-from-stupid-sex for that. And abstinence-from-stupid-sex is basically teaching people to be faithful to their partners.

All in all, there would still have to be 9 times more new individual sex acts happening (whether between new participants or due to increased promiscuity) with condoms than there were previously before a negative effect was seen. I do not believe that would happen. Just like I said earlier, there will likely be some back slip when new habits are established because of condom use but one day may continue without condoms, but unless 4 out of every 9 of those new sex acts eventually become unsafe sex acts, the net benefit will still be positive.

Are condoms the only, or even complete, answer? I never said they were. But the hypothesis that they will make the situation worse does not have numerical backing.

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Re: Condoms and HIV/AIDS in the developing world

Postby Dream » Sat Mar 21, 2009 4:54 pm UTC

Azrael wrote:Are condoms the only, or even complete, answer? I never said they were. But the hypothesis that they will make the situation worse does not have numerical backing.

What about in communities where nine in ten sexual acts involves one or more HIV+ partners? Because that's what you have to address where there is a 90% infection rate. If almost everyone is HIV+, any increase in sexual activity at all, and any increase in promiscuity will likely add to the problem. Condoms in such a situation are not a solution, and in very different terms than the Pope might like, abstinence might have a very positive effect. If such communities are not assisted greatly in dealing with their epidemic, then all other attempts will be futile, as reinfection will undo any good work in their own and other communities. Just like the risk that gay communities in the West might restart the 1980's epidemic by ceasing condom use now, African communities might render useless any good work by having their extremely high infection rates passed on through condom use in what is for a 90% infection rate, unsafe sex.
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Re: Condoms and HIV/AIDS in the developing world

Postby Azrael » Sun Mar 22, 2009 6:44 pm UTC

Let's take it to the farthest extreme (because 9 in 10 couplings have at least one HIV+ partners could mean anywhere between 4.5 or 9 in 10 are HIV+, and that's pretty vague) and say that everyone sexually active already has HIV and the transmission rate is 100%. This is certainly the worst-case scenario.

Now, new participants using condoms have a 10% risk of getting HIV. People abstaining have 0% risk. Teaching condom use would only have to be 10% more effective than teaching abstinence for it to break even. Again, I think that's an EASY margin.

Because people will have sex. And in the HIV discussion, it's not just trying to tell teenagers not to have sex until marriage because of a moral stance or a social attempt to reduce teenage pregnancy. This involves *everyone*. Adults will have sex, end of story.

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Re: Condoms and HIV/AIDS in the developing world

Postby Dream » Sun Mar 22, 2009 10:38 pm UTC

Azrael wrote:Because people will have sex. And in the HIV discussion, it's not just trying to tell teenagers not to have sex until marriage because of a moral stance or a social attempt to reduce teenage pregnancy. This involves *everyone*. Adults will have sex, end of story.


Sticking to the example of the extremely high infection rates, I don't think it's so black and white. We aren't talking about a moral prohibition, nor societal pressure, shame or even religious attempts to control reproduction and the family. These are the usual reasons for inhibiting sexual activity in non epidemic regions and not one of them comes close to having the power to stop people from having sex. We are talking about dealing with a lethal disease, and over a lifetime of casual sex, an extremely high chance of contracting it. I think this is a much stronger motivation. It won't work for everyone, perhaps not even for most people. But if, say 20 or 30% of a new generation got it into their heads that sex can be lethal, and is so completely not worth it that it isn't even an option,then a huge number of lives would be saved.

More later, have to go to work now.
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Re: Condoms and HIV/AIDS in the developing world

Postby Clumpy » Tue Mar 24, 2009 5:51 am UTC

One of my professors was in Africa for a good decade researching the AIDS epidemic and preventative measures, and he saw one problem as such:

In Africa, he said, the cultural belief among many is that love and trust develop between two people precisely when you put yourself at risk for them. Protection among those people is unlikely as they value the intimacy associated precisely with not protecting yourself. And education and wealth are actually a correlating factor with HIV infection in Africa. Thus explaining the risk will not necessarily help.

Much of the recent work has attempted to work through the culture by promoting the concept of "zero grazing" - in essence promoting faithfulness by working off of cultural concepts and encouraging monogamous sexual relationships. When explained by the angle of starving off of the virus without sacrificing trust and unity people definitely understand.

Anyway, the gist was that trying to project our culture onto others is not necessarily a way to solve the problem. Keep in mind that I've never been to Africa, and despite reading a little on the topic this may be very wrong.

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Re: Condoms and HIV/AIDS in the developing world

Postby Dream » Tue Mar 24, 2009 1:13 pm UTC

Clumpy wrote:In Africa, he said, the cultural belief among many is that love and trust develop between two people precisely when you put yourself at risk for them. Protection among those people is unlikely as they value the intimacy associated precisely with not protecting yourself.


I'm really not sure about this anecdotal evidence, in that it appears to argue that "Africans" are all of a particular stripe, which is a generalisation, and that they don't know what's good for them, which is patronisingly paternalistic. But the point of the argument is important: Condom use is a social issue, not a medical one, and meddling with entire societies in a blinkered, Western-centric way is a hamfisted highway to disaster. Africa is not the San Francisco gay community, nor is it Brazilian prostitutes, nor is it people who got tainted blood transplants.
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Re: Condoms and HIV/AIDS in the developing world

Postby Clumpy » Tue Mar 24, 2009 2:32 pm UTC

Dream wrote:
Clumpy wrote:In Africa, he said, the cultural belief among many is that love and trust develop between two people precisely when you put yourself at risk for them. Protection among those people is unlikely as they value the intimacy associated precisely with not protecting yourself.


I'm really not sure about this anecdotal evidence, in that it appears to argue that "Africans" are all of a particular stripe, which is a generalisation, and that they don't know what's good for them, which is patronisingly paternalistic. But the point of the argument is important: Condom use is a social issue, not a medical one, and meddling with entire societies in a blinkered, Western-centric way is a hamfisted highway to disaster. Africa is not the San Francisco gay community, nor is it Brazilian prostitutes, nor is it people who got tainted blood transplants.


It's mainly the "unified culture" thing that made me include the caveat that I have no first-hand knowledge of the subject. Even if the attitude I described is prevalent over a given area within the continent, Africa is, of course, anything but culturally homogenous. Still I don't think that making this argument is necessary patronizing in and of itself (though, like all similar arguments it could be co-opted by racists or misguided people eager to perpetuate the "foolish children" stereotype).

For example, I see this as a comparable statement: Americans tend to take elevators rather than stairs even if they're not late because they see it as a matter of convenience, and value the feeling of being "full" even if it means that they eat more than is healthy. Ultimately, correcting this problem will not involve instructing the populace in principles of health but working to change these cultural norms to conform with healthy ones.

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Re: Condoms and HIV/AIDS in the developing world

Postby Rinsaikeru » Tue Mar 24, 2009 8:05 pm UTC

A lot of the dispute about condom use in the developing world has much more to do with the sort of aid other countries are willing to provide and the impact this has on the cultures it affects. If aid organizations focused on providing resources and ceased trying to direct the specifics of what resources were demanded a lot of this would fall to the wayside I think.

Access to condoms, education about the spread of STIs, education about abstinence as a preventative are all good things that could each be employed simultaneously. Telling people--"oh, you'd better not have casual sex because of AIDS so repress your sex drive indefinitely for your own safety." Just doesn't seem like a workable solution to me.
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Re: Condoms and HIV/AIDS in the developing world

Postby Ixtellor » Tue Mar 24, 2009 8:25 pm UTC

Azrael wrote:Now, new participants using condoms have a 10% risk of getting HIV. People abstaining have 0% risk


If you want to further complicate your percents, you might include blood transfusions, and violent attacks by people with aids, and IV drug users.

I guess I am only responding because the risk of contracting HIV is not zero by people that abstain and for some reason it bothered me.


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Re: Condoms and HIV/AIDS in the developing world

Postby Chen » Wed Mar 25, 2009 4:56 pm UTC

Ixtellor wrote:
Azrael wrote:Now, new participants using condoms have a 10% risk of getting HIV. People abstaining have 0% risk


If you want to further complicate your percents, you might include blood transfusions, and violent attacks by people with aids, and IV drug users.

I guess I am only responding because the risk of contracting HIV is not zero by people that abstain and for some reason it bothered me.


Ixtellor


Presumably though those risks apply to those abstaining AND those who are using condoms so it shouldn't matter in the end.

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Re: Condoms and HIV/AIDS in the developing world

Postby mightymouse1584 » Wed Apr 15, 2009 6:11 pm UTC

Durandal wrote:f one is infected with HIV and having intercourse with someone who isn't, condoms HAVE to work. But mostly due to human error, they don't. At least not all the time. (The quoted failure rate is 10% [source])



I think the failure rate may actually be much higher than you expect. According to the FDA, the expected number of pregnancies per 100 uses with a condom is 11 [source]. 11% of sexual encounters that use condoms will result in a pregnancy (under normal, not perfect use). That being said, if a condom fails, does a woman necessarily get pregnant? Of course not. The likelihood that a woman will become pregnant without any sort of prevention from one act of sex is about 1 in 3 (unfortunately, I dont have a source right now to back this up, but I'm fairly certain that info is accurate). Put this all together and the actual rate failure could rise all the way to 30%. Even if we use a low-ball estimate of 20% (under normal use), that number is still frighteningly high.

Still, I believe promoting use of condoms will result in a net positive, but the key here is in spreading knowledge about how to use them. According to the FDA, under perfect use the pregnancy rate plummets to 2%. The problem is that so many people assume they already know and never even bother to look. Even in the United States and other first world countries I would wager to guess the majority of the population has no idea how to effectively use a condom. Why else would the FDA include numbers for regular use and perfect use?

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Re: Condoms and HIV/AIDS in the developing world

Postby Enuja » Wed Apr 15, 2009 7:52 pm UTC

mightymouse, you are misinterpreting the statistics in the .pdf you linked. It is not 11% of heterosexual insertive encounters with condoms that result in a pregnancy. Instead, 11% of heterosexually active women using condoms normally get pregnant in a given year. The number of insertive sex acts each women participates in a year is highly variable, but can be assumed to be greater than one. As your source says, 85% of women trying to get pregnant will get pregnant in a year.

The .pdf of a 2003 news article that Durandal linked does not define "failure rate", but it does compare the HIV failure rate to the pregnancy failure rate. Which suggests that all of the math in this thread so far overestimates the risk of condom failure in a single sex act. I found one study on per-use condom breakage and slippage from monogamous, heterosexual, experienced users, using condoms as a pregnancy preventative, and the per-use failure rage is less than 1%.

The Wikipedia (condom page) says (and contains the link to a .pdf of the NIH study)
According to a 2000 report by the National Institutes of Health, correct and consistent use of latex condoms reduces the risk of HIV/AIDS transmission by approximately 85% relative to risk when unprotected, putting the seroconversion rate (infection rate) at 0.9 per 100 person-years with condom, down from 6.7 per 100 person-years.


Study I mentioned:
M.J. Rosenberg and M.S. Waugh, Latex condom breakage and slippage in a controlled clinical trial, Contraception 56 (1997), pp. 17–21.

There are also a fair number of studies about sero-conversion in heterosexual monogamous couples were one is seropositive and one is seronegative.

de Vincenzi, I. 1994. A longitudinal study of human immunodeficiency virus transmission by heterosexual partners. New England School of Medicine 331(6) 256 couples, of which 124 used condoms consistently. Among inconsistent users, 4.8 per 100 person-years (95% CI = 2.5–8.4) seroconverted, and none of the consistent condom users seroconverted.

Davis, K.R. and Weller, S.C. 1999. The effectiveness of condoms in reducing heterosexual transmission of HIV. Family Planning Perspectives 31(6):272–279. A meta-analysis of 25 studies.

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Re: Condoms and HIV/AIDS in the developing world

Postby mightymouse1584 » Wed Apr 15, 2009 8:44 pm UTC

Indeed, I stand corrected. 11% over the course of a year, as opposed to 11% of individual encounters is a more reasonable reading of the data. Still, The important thing to take away from this is that the condoms must be used correctly. Condoms will result in a net positive in the fight against HIV/AIDS regardless of casual vs perfect usage, even if the level of promiscuity rises, but ensuring proper usage will ensure a much more significant victory.


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