Has condom distribution increased the spread of HIV/AIDS in Africa?

Question

Related: Do condoms have large enough holes for HIV to pass through?

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Back in Mar 2009, Pope Benedict XVI visited Africa and stated that condom use was not the answer to Africa's HIV/AIDS problems.

• MSNBC: Pope: Condoms not the answer in AIDS fight
• The Guardian: Pope claims condoms could make African Aids crisis worse

For quotes, this is from the MSNBC article:

"You can't resolve it with the distribution of condoms," the pope told reporters aboard the Alitalia plane heading to Yaounde. "On the contrary, it increases the problem."

And this from the Guardian:

The pontiff, speaking to journalists on his flight, said the condition was "a tragedy that cannot be overcome by money alone, that cannot be overcome through the distribution of condoms, which even aggravates the problems".

I get that the Catholic stance of monogamy and non-premarital sex would certainly reduce the spread of HIV/AIDS; what I'm skeptical about is that distribution of condoms would aggravate or increase the problem. Some claim that the pope was right -- Washington Post: Condoms, HIV-AIDS and Africa - The Pope Was Right:

In 2003, Norman Hearst and Sanny Chen of the University of California conducted a condom effectiveness study for the United Nations' AIDS program and found no evidence of condoms working as a primary HIV-prevention measure in Africa... Since then, major articles in other peer-reviewed journals such as the Lancet, Science and BMJ have confirmed that condoms have not worked as a primary intervention in the population-wide epidemics of Africa.

Has increased condom distribution led to an increase in the spread of HIV/AIDS in Africa?

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Similarly, some sub-questions might be:

• Has condom use been shown definitively to reduce the spread of HIV/AIDS (compared to non-condom use situations)? (This seems obvious, but it might still be helpful)
• Is the cause of the rise or plateau of infection rates to do with condoms themselves or usage rates that are too low?
• Put one last way, if condoms were universally available and used at a very high rate, would we see a decrease in HIV/AIDS transmission rates?

This seems to circulate around quite a bit (that the pope was right and that making condoms available has actually increased the problem, perhaps because condoms themselves don't work), especially amongst Catholics; I thought it might be helpful to disambiguate what's actually going on.

Answer 1

No. it has done the opposite. Condoms are given away for free in South Africa. (Consider me the source. I am South African.) Since the introduction of condoms, there is a reduction in new HIV infections.

According to The effect of changes in condom usage and antiretroviral treatment coverage on human immunodeficiency virus incidence in South Africa: a model-based analysis:

Despite significant structural differences, both of the models considered in this analysis suggest that adult HIV incidence in South Africa has declined significantly since the year 2000. In addition, both models suggest that most of this decline can be attributed to the effect of increased condom usage, and that some of the decline may be attributable to the impact of [antiretroviral treatment] on the infectiousness of individuals with advanced HIV disease.

Answer 2

You quoted Norman Hearst, so I'll start there. According to Hearst,

First, condoms are 85-90% effective for preventing HIV transmission when used consistently.  We then looked at whether condom promotion has been successful as a public health strategy – something very different from individual effectiveness.  Here we found good evidence for effectiveness in concentrated epidemics.  For example, condoms made an important contribution to controlling HIV among gay men in places like San Francisco and epidemics driven by commercial sex in places like Thailand.

We then looked for evidence of a public health impact for condoms in generalized epidemics.  To our surprise, we couldn’t find any.  No generalized HIV epidemic has ever been rolled back by a prevention strategy based primarily on condoms.  Instead, the few successes in turning around generalized HIV epidemics, such as in Uganda, were achieved not through condoms but by getting people to change their sexual behavior.

The studies I found closely match Hearst statement above that "condoms are 85-90% effective for preventing HIV transmission".

Reducing the risk of sexual HIV transmission: quantifying the per-act risk for HIV on the basis of choice of partner, sex act, and condom use.

A pooled analysis of studies suggested that condoms are 90–95% effective in preventing HIV transmission, if used consistently. Model-based estimation also indicated that condoms decrease the per-act probability of male-to-female transmission by about 85–95%. Another study reported that condoms broke or slipped off in approximately 4% of coital acts. For our model we assumed the per-act probability of condom failure due to incorrect use, slippage, and breakage to be 5%. Hence, using a condom provides a 20-fold decrease in risk of acquiring HIV infection, per act."

Another interesting study from the New England Journal of Medicine found couples with an HIV positive partners, that used condoms for every sexual episode, showed no transmission of HIV.

With those studies, I think it is safe to say that condoms are effective at preventing HIV.

But knowing this, Hearst still argues "condoms are not effective at rolling back HIV epidemics". So, if condoms can stop HIV transmission almost 95% of the time, why aren't condoms effective at stopping HIV epidemics?

The truth is, I couldn't find a good answer to this question. I think it is likely Hearst is wrong. Just because HIV rates increased in some countries, when condom distribution increased, does not mean that they are linked. Correlation doesn't imply causation. Condoms can be distributed, but cannot stop epidemics if they aren't used.

But I could also easily argue the other side. A HIV prevention based primarily on condoms ignores the real problem: sexual promiscuity. Condoms are not an effective prevention because their simply not used. The best HIV prevention programs concentrate on behavourial changes like being abstinate or having only one sexual partner. The problem is behavour, not use of condoms. Condoms promote the idea of sexual promiscuity. People think they can be sexually promiscuous and just use a condom for protection -- I'll use a condom and I'll be safe. When it comes down to the sexual act though, condoms are just forgotten, hence increasing the spread of HIV.

This is only speculation on my part. Hopefully others will take the torch from here and provide more evidence based facts.

So the answer to your question is, I don't know.