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Good News on Global AIDS

Thu, 22 Jul 2010 09:00:31 -0400

Reducing Risk, Increasing AIDS

Wed, 23 Jun 2010 00:56:00 -0400

The predominant Western approach to preventing the spread of AIDS in Africa has failed. Though in theory the risk reduction strategies favored by Western governments and aid agencies”handing out condoms, promoting counseling and testing, and treating other sexually transmitted infections (STIs) to block HIV transmission”can “work” in theory, they have not done so in practice. In Africa, despite years of promised improvements, they have not brought any downturn at all.

But a handful of African countries have actually forced down the AIDS rates, each of them by changing behavior ”particularly reducing sexual partnerships”not through the heavily promoted risk reduction measures.

Well before western donors and condoms arrived on the scene, Uganda had cut its level of casual sex by two-thirds and subsequently its HIV rate by two-thirds. Several years later, Kenya replicated this success. A few other countries have also done so, with partner reduction always the most important factor.

In sharp contrast, South Africa has maintained high rates of multiple (and concurrent) partnerships and, despite its vigorous promotion of condoms, still suffers from persistently high rates of HIV infection. The same can be said of many of its neighboring countries, which lead the world in the prevalence of HIV, with some 15 to 35 percent of all adults infected.

These successes and failures are, tellingly, too often treated in a manner inversely proportional to their merits. Behavior change, though responsible for success, remains the least emphasized approach, while risk reduction invariably receives the benefit of the doubt despite its failure to deliver as promised. Its disappointing results always mean that efforts”along with funding”must simply be doubled.

Many in the AIDS Establishment will only unreservedly applaud success if it comes through the technical means promoted by Western governments and activist groups. In a 2005 PBS documentary, UNAIDS’ executive director Dr. Piot refused to concede that behavior change played the paramount role in Uganda’s unparalleled success. “But we also know,” he added, “that no country has been successful in bringing down the number of new infections of HIV without strong condom promotion.”

To viewers who have never had reason to think twice about the issue, this might sound like a sober assessment. Human sexual behavior, we tend to assume, is hard to change and so the most effective way to reduce the number of people getting sexually transmitted diseases must therefore be to reduce the risk of sexual activity. That appears to many people just common sense.

But Uganda clearly refutes Piot’s claim, as does the fact that the countries with the most robust condom promotion programs have some of the most severe AIDS epidemics in the world. The evidence suggests that common sense may be wrong.

For starters, people tend to take greater risks when they feel protected by technical innovation. In a state of the art program in Uganda, for example, those explicitly encouraged to use condoms ended up at greater risk than the control group not exposed to the sophisticated intervention, because they had more sexual partners than those not told to use condoms. People have also been seen to take greater risks when antiretroviral therapy for HIV/AIDS became available.

This “risk compensation” or “behavioral disinhibition” is now, fortunately, receiving more attention in scientific circles. It is one reason why vigorous promotion of risk reduction”even if it “works” in isolated cases”can do more harm than good. The “common sense” presupposition that condoms will decrease infection rates does not easily give way to the common sense observation that promoting devices capable of reducing risk encourages people to take more risks.

But risk reduction measures have a deeper and more damaging defect: a deflating absence of hope. They too often imply that we cannot influence behavior”that the best we can hope for is reducing and controlling the damage of behavior people will engage in whatever we say. More damagingly, they too often imply that we cannot change our behavior, that in matters of sexuality in particular we are doomed to live dangerously, that we are too weak to do what is best for us.

Thoughtful strategies to change behavior, on the other hand, reinforce the human capacity to recognize and choose what is good. As the Ugandan experience has proved, all people”especially the young”respond to this message when it is sincerely delivered.

The hopelessness at the heart of the risk reduction philosophy is rarely noticed and its effects almost never described or included in the evaluation of the methods for reducing AIDS in Africa. The scientific literature and the popular press instead portray technical, risk reduction measures as the only enlightened and the only truly practical approach to reducing AIDS in Africa. But that reflects a profoundly elitist and patronizing philosophy, which is an insidiously destructive one because people threatened with AIDS most need hope for the future”hope to live free of disease, discord, fear, and inner turmoil.

A colleague of mine in Africa put it like this: “Ideals are like the stars. We may not reach them, but we set our course by them.” If we hope for nothing, as someone has said, we will get what we hoped for. Advocates of risk reduction, though, seem threatened by such an ideal, maybe because it implicitly reproaches the modern autonomy project or seems to support “traditional morality.”

In fact, UNAIDS had itself commissioned, a couple years before Piot’s remark, a revealing comprehensive study of the impact of condom promotion on HIV transmission in the developing world. I presume Piot got a copy of the results. I did. Many of my colleagues did. It found, quite plainly, that “prevention campaigns relying primarily on the use of condoms have not been responsible for turning around any generalized epidemic.”

These results, according Norman Hearst, a highly respected epidemiologist at the University of California at San Francisco who led the study (and is to this day called upon to give testimony before Congress), were not what “UNAIDS wanted to hear at all.” Instead of welcoming the findings and adapting HIV prevention strategies accordingly, UNAIDS first tried to alter them, and then refused to publish them. The results were finally published in a peer-reviewed journal, Studies in Family Planning .

UNAIDS is usually very eager to insist on “the right to accurate information” about condoms; such flagrant suppression of its own highly relevant findings in this case fails others miserably. This is important to drive home, since it is the Catholic Church that is routinely portrayed as holding fast to dogma at the expense of human lives.

UNAIDS’ burial of disinterested research could be considered a public distortion”by omission”of “scientific evidence.” Dr. Piot’s remark on PBS could fairly be characterized as an “outrageous and wildly inaccurate statement””precisely the charges that the prestigious English medical journal The Lancet baselessly leveled at the Pope last year, after he suggested condom promotion isn’t the solution, and might even do harm.

But the downsides are getting harder to ignore. Even in Uganda, HIV prevalence has gone back up in recent years, as Western donor demands for risk reduction replaced the country’s own original emphasis on behavior. We are at an important juncture”and not just for Africa, where a fortunate minority are now able to access treatment, but where two million more people get HIV infections every year.

The number of new HIV cases in the Unites States has remained constant for the last decade, suggesting that our HIV risk reduction strategies are not working that well here either. High rates of other common STIs persist unabated or are even rising; one in four teenage girls (aged fourteen to nineteen) has an STI, according to the Center for Disease Control. Other Western countries have seen some STIs double or triple over the past two decades.

Despite these grim trends, we are constantly told that reducing the risk of sexual behavior, not limiting the practice of it, is the answer. It has be the answer, when the West’s mix of utilitarianism, individualism, and relativism puts addressing behavior off limits. Changing behavior is not only a valid and sensible public health message, it is the most urgently needed one.

We should expect our public health authorities not to pass on the prevailing strains of cultural thought uncritically, but to speak against them when people’s futures and their lives depend upon their speaking the truth.

Matthew Hanley is the author, with Jokin de Irala, of Affirming Love, Avoiding AIDS: What Africa Can Teach The West , recently published by the National Catholic Bioethics Center. He is also a regular contributor to The Catholic Thing . His ” Should Catholic Charities Settle for Harm Reduction ” appeared in March.

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Should Catholic Charities Settle for Harm Reduction?

Wed, 24 Mar 2010 10:21:00 -0400

Sr. Maureen Joyce, CEO of Catholic Charities in Albany, New York, described its recent decision to implement a needle exchange program for HIV/AIDS prevention as mere “common sense””a perfect reflection of the conventional, which is to say misguided, wisdom of favoring “harm reduction” techniques over other methods of confronting drug abuse. But that is also an unflattering way to characterize a decision they took five years to reach: Does it normally take so long to decide to support an intervention whose moral acceptability and practical benefits are supposedly so obvious?

An honest and thorough investigation into the matter, conducted with a basic appreciation for the agency’s Catholic identity, would have led them to seek out alternative courses of action. They would have found both that the Catholic Church has clearly, reasonably, and decisively opposed such programs and that needle exchange programs do not work.

The isolated act of dispensing a clean needle to prevent disease may not always be evil in itself, but that does not mean the program represents a clear-cut case of the morally acceptable toleration of a lesser evil to prevent a greater one, as they have claimed. There are many other considerations: How reliably do they achieve reductions in disease, for example, and how acceptable are their considerable negative, if unintended, side effects, particularly compared to the available alternatives?

The reality is that the evidence for Needle-Exchange Programs (NEP) is much too feeble to warrant the reflexive enthusiasm of their proponents. Dr. Kerstin Käll, a Swedish psychiatrist who specializes in addiction, reviewed the relevant literature and found nine studies that examined the impact of needle-exchange programs on HIV incidence (the most relevant indicator of success or failure). Only one demonstrated a protective effect, while one found NEP users to be at higher risk of contracting HIV. The rest were inconclusive. Käll also found methodological errors in several studies which have helped perpetuate the mantra that NEP programs achieve reductions in HIV.

The fact is that there is no reliable evidence which confirms that such programs deliver as promised. Yet Angela Keller, who joined Catholic Charities Executive as director of AIDS services after working five years at the local AIDS Council, asserts: “This is a proven method used around the country, but there has been a huge gap in this area that nobody was stepping up to fill.”

Perhaps Catholic Charities was also simply unaware of the King Cross Injecting Room in Sydney, Australia. The Sisters of Charity proposed to operate a Medically Supervised Injection Center (MSIC) in Sydney on the premises of St. Vincent’s Catholic Hospital. In 1999 the Congregation of the Doctrine of the Faith found that although the proposal did not constitute formal cooperation in the evil of using illicit drugs, it did constitute an “extremely proximate” (unacceptable) degree of material cooperation “in the grave evil of drug abuse and its foreseeable bad side effects.” Formal cooperation is never tolerated. Material cooperation, though undesirable, may at times be permitted, but strong enough reasons for doing so simply were not present in this case.

The CDF recognized that the sisters intended to minimize harm and were not intending to encourage or normalize drug use. But they contended that the proposed center would nonetheless “certainly and immediately facilitate drug abuse and the evils intrinsic to it.”

It turns out that the CDF was quite prescient. A subsequent evaluation of the program’s results (conducted by the center itself) revealed an overdose rate 36 times higher in the injecting room than on the surrounding streets, implying that clients “may have taken more risks and used more heroin in the MSIC.” If the addicts deliberately chose to take more risks at the MSIC (which was better able to rescue them from overdoses) than they would have otherwise, this implies that addicts possess a certain, oft-denied control over what they do”an ability to make rational decisions or, it could be said, to work the system.

The center’s own evaluation also found that clients took only one out of every 35 of their injections inside the supervised center. The CDF had wisely reasoned years earlier that the program’s benefits would only kick in “if the drug users were to make the MSIS their habitual place to inject drugs, for which there is no assurance.” Another justification for the center (and many similar initiatives) is that it would serve as vital means of referral to rehabilitation or detoxification programs”yet very few were in fact ever referred to, much less received at, Sydney’s rehab centers. No improvements in the transmission of HIV or Hepatitis C and B were detected.

The bottom line is that this costly measure showed little pragmatic benefit.

On a deeper level, what should we think of a philosophy which maintains that encouraging people to refrain from ongoing drug abuse is to ask too much, or worse, to cast judgment upon the people being served? As Keller expressed this sentiment: “they [addicts] hopefully get a feeling that we’re not there to judge them.”

And what should we think of a philosophy whose goal is to sanitize the entire enterprise of addiction ad infinitum ? Many who are prescribed methadone as a substitute for heroin stay on it for years, or even decades. Most Scotsmen, for example, never get off it. Methadone is itself responsible for a great many deaths by overdose today”in some cases, proportionally higher than those by heroin overdose.

Practitioners of public health regularly profess to be deeply concerned about the root causes of disease. Why, then, are they so satisfied in this case with superficial measures that cannot begin to rectify deeper wounds?

Harm-reduction measures may protect some people from some infections some of the time; as social policy, however, it is tantamount to surrendering to addiction and the personal and social costs of addiction. Countries that have emphasized harm reduction philosophies, such as the U.K. and Canada, have been rewarded with persistently high rates of drug abuse, disease (including staggering Hepatitis C epidemics), and crime. But dismal results are insufficient cause to disrupt the cozy arrangements whereby public agencies”selling the technical fix”and their non-profit collaborators profit from patronizing “beneficiaries,” whose own individual responsibility is outsourced and whose capacity for change is downsized.

No matter how discouraging the broader trends, the belief persists that, if we only get more sophisticated in our “delivery” of technical “services” to more and more people, all will be better, if not quite well. Sr. Joyce placed her ardent support of needle exchange in those terms: “I strongly believe in this. It will save lives.”

But if it boils down to belief , is it not much more humane, compassionate, and yes, constructive, to believe that a life free of drug abuse is indeed possible, and worth aiming for? It might be excruciating and entail facing what no one would ever want to face. Without support from peers and reinforcing cues from society, it may indeed be a long shot. (If even Catholic Charities is doling out needles from a van, where shall one go for a way out?) With the support and structure provided by groups like Catholic Charities, however, the prospects for transformation improve.

Therapeutic communities (which are present in New York) provide that support and achieve that transformation. While investigating approaches to drug rehabilitation in 2006, I visited a program called Fazenda da Esperanca (Farm of Hope) in João Pessoa, Brazil. Recovering addicts found their days structured with work and discipline. They encountered support from others in the community and the obligation to reciprocate it in turn. Regular prayer provided many with a sense of healing. The young manager had himself recovered from addiction in this community and turned down attractive opportunities”including marriage”after leaving in order to help others transform their lives in the same way.

There are thirty-one Fazendas in Brazil; they report that 84% overcome their addiction. Even deeply traumatized lives regain purpose and meaning. Benedict XVI himself visited Fazenda da Esperanca in 2007”a profound testament to their message and success. He urged those who have recovered to be ambassadors of hope”not harm reduction”for others.

Public health officials need to reevaluate poorly performing harm reduction policies, which advance an anthropology that despairs of the possibility of transformation, under cover of technical prowess. Catholic agencies would maintain integrity and provide greater service to the public by remaining true to their Catholic identity by being witnesses to hope”even if that means missing out on a government grant. Even if government programs were models of efficiency, there will always be a need for authentic charity.

Sources: The Case for Closure (a report on the results of the King’s Cross program); The Effectiveness of Needle Exchange Programmes for HIV Prevention (a description of Dr. Käll’s findings on needle exchange programs).

Matthew Hanley is, with Jokin de Irala, M.D., the author of Affirming Love, Avoiding AIDS: What Africa Can Teach the West , to be published by the National Catholic Bioethics Center in April 2010 .

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