Prevention and Risk Compensation.
Are some Public Health responses to AIDS and other STI´s failing?
Jokin de Irala MD, MPH, PhD (University of Navarra)
Taken from the book: M Hanley and J de Irala. Affirming Love, Avoiding AIDS: What Africa Can Teach the West. NCB 2010.
For the IEEF-EIFLE congress, Paris 4-5 October 2013
Introduction
Among adolescents, sexually transmitted infections (STIs) and unplanned pregnancies remain important public health problems, despite long-term efforts to prevent them. Several risk factors for STIs exist and prevention strategies include the delay of the onset of sexual relationships and the reduction of the number of lifetime sexual partners. For those who choose not to totally avoid risks, public health recommendations include risk reduction strategies and promote the increase, correct and consistent use of condoms. In addition, the 2004 Lancet consensus sought to prioritize the proper order of emphasis among all these three messages.
Condoms offer better protection for human immunodeficiency virus (HIV) and pregnancy than for other STIs such as genital herpes or human papillomavirus. However, protection is not complete in any of these cases, even assuming optimal use. Health educators, parents and the media in general could benefit from knowing the effects that placing emphasis on condom effectiveness may have when informing adolescents. On one hand, this strategy may increase condom use among adolescents, thus reducing individual risks. On the other hand, conveying the message that condoms offer complete protection might cause a perception of safety that may lead to an earlier onset of sexual relations or to a higher number of sexual partners (risk compensation phenomenon). Hesitations about how to classify these possible effects underlie, for example, the debates which took place concerning condom labels. Specifically, in 2005, the Food and Drug Administration proposed that labels should say: “When used correctly every time you have sex, latex condoms greatly reduce, but do not eliminate, the risk of pregnancy and the risk of catching or spreading HIV”, while others argued that saying “do not eliminate” might cause people not to want to use condoms, which would increase risks.
The Public health responses to STI Epidemics
Promotion of condoms, voluntary testing and counseling, and treatment of sexually transmitted infections have had a negligible impact on HIV incidence in Africa. Nevertheless, these risk reduction interventions still form the backbone of the World Health Organization’s “comprehensive” HIV prevention strategy. The World Health Organization was criticized in 2007 more broadly—regarding a host of other health matters—for rarely using systematic reviews or concise summaries of findings in developing their recommendations. Risk avoidance behaviors have made decisive contributions in national success stories, and risk reduction measures have been a major disappointment although there are instances where a risk reduction strategy has helped avoid infections. Condoms, for example, may have protected some individuals at a certain time. However they have not had a protective epidemiological impact at the population level. From a purely pragmatic point of view, there remain large and serious concerns about the actual impact and efficacy of risk reduction strategies. Pointing this out is one thing; but in addition, some people are uneasy about the messages that the strategies convey about the underlying moral and philosophical foundations of some of these messages.
In many countries, HIV transmission rates have remained high and even grown, despite a considerable increase in condom promotion and use. Condom sales in Botswana increased from one million in 1993 to three million in 2001, while HIV prevalence among pregnant urban women increased from 27 to 45 percent. There is great incongruence between the theoretical effectiveness of the condom at the individual level, and the public perception of its actual effectiveness in practice. This crucial distinction is generally not well understood. This remains the case particularly in the Western media, even though respected researchers were pointing out as early as the year 2000 that “massive increases in condom use worldwide have not translated into demonstrably improved HIV control in the great majority of countries where they have occurred.” A comprehensive review of the impact of condom promotion on HIV transmission in the developing world concluded that condoms have not been responsible for substantially changing any of the large African epidemics. This study was originally commissioned by UNAIDS and conducted by researchers at the University of California at San Francisco such as Dr. Norman Hearst, who led the study. He was surprised by the results and found that they 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 the findings and then refused to publish them. The findings were so threatening to UNAIDS that the researchers were finally forced to publish them on their own in a less visible peer-reviewed journal, (Studies in Family Planning). Hearst explained that UNAIDS “released their own separate statement about how wonderful and effective condoms are. This did not have our names on it, nor would I have wanted it to.” Hearst had worked with the UNAIDS for years prior to this study but never received an explanation for their actions. This episode shows the priorities of the leading AIDS agency of the United Nations. Although normally quick to insist on the right to “accurate information” about condoms, in this case UNAIDS placed their own ideological preferences above the welfare of those whom they are charged with protecting. In fact, this disregard for highly relevant evidence reveals their relative lack of interest in questions of science; rather, they seem to “have considered the disease a profound threat to the ideology of the sexual revolution, and have at times put both the protection and the promotion of this ideology ahead of public health.” These findings were a threat to UNAIDS and they encouraged Hearst to remark, with great independence and integrity, that what is needed is to “move beyond debating how well condom promotion might work to examining how well it has.” The evidence has led Hearst and other respected scientists to say that campaigns encouraging condom use will do more harm than good if they lead young people to have sexual relations, especially if the young people end up using condoms inconsistently and in situations where there is a high risk of transmission. A campaign promoting condom use does more harm than good if it fosters sexual practices that are riskier than those in which people would engage had they not been exposed to the campaign. Riskier behaviors are associated with increases in HIV infection, and “this seems to strengthen the argument that interventions are needed to lower the levels of higher-risk sexual activity,” according to Harvard researcher Edward C. Green in his 2004 book, Rethinking AIDS Prevention. Green concludes that “adding condoms to high-risk behavior does not seem to have much impact on the consequences of the behavior. Condoms evidently do not protect against HIV infection as well as they are supposed to and one of the crucial issues related to the poor success of risk reduction strategies is “risk compensation”.
Risk compensation
Risk compensation is a crucial weakness in the risk reduction approach and is now receiving more attention by scientists: people may increase risk-taking behavior because they perceive themselves to be at less risk due to a technological innovation. This behavioral “disinhibition” is sometimes called “risk compensation” because the benefits of an intervention designed to reduce risk can be offset if enough people who use it become careless about other basic and behavioral preventive measures or give them up. For example, people who made greater use of sunscreen suffered an increase in skin cancer because they compensated for the sunscreen’s protective effects with longer exposures to the sun. John Richens, a British scientist who has done pioneering research on this phenomenon, argued in a landmark 2000 Lancet article that risk compensation was responsible for the initial failure of seatbelt laws to prevent deaths in traffic accidents. Many drivers assumed the seatbelt would protect them even if they drove more recklessly or under the effects of alcohol. In the same article Richens drew the parallel to condoms and sexually transmitted infections like AIDS by noting, “A vigorous condom promotion policy could increase rather than decrease unprotected sexual exposure, if it has the unintended effect of encouraging greater sexual activity.” Risk compensation has been observed with a number of HIV/AIDS-preventive measures, such as the promotion of condom use, the introduction of antiretroviral therapy, and post-exposure prophylaxis (taking antiretroviral therapy soon after suspected exposure to the virus in hopes that the virus will not take hold in the body). Other measures like voluntary counseling and testing and the treatment of sexually transmitted infections may also have a disinhibiting effect. If the “A” and “B” components of the ABC preventive approach (The A of ABC stands for abstinence and refers to education and support for people to postpone sexual initiation and to avoid sporadic sexual relations. The B stands for be faithful and represents the recommendation to have mutually monogamous sexual relations with an uninfected person. The C stands for condom use, based on the knowledge that condoms may reduce the risk of infection but will not eliminate the risk altogether) were properly emphasized as the safest and most effective way of preventing HIV infection, with the warning that condoms substantially reduce the risk but do not eliminate it, those who choose condom use would be better informed about the concept of risk reduction and might be more motivated to avoid the slippery slope of risk compensation. Risk compensation surfaced as a major theme during Pope Benedict XVI’s trip to Cameroon in March 2009. A reporter asked the Pope to defend the Church’s promotion of monogamy and opposition to condoms in the fight against AIDS, especially since such positions are “frequently considered unrealistic and ineffective.” He responded in part by saying that “the scourge cannot be resolved by distributing condoms; quite the contrary, we risk worsening the problem.” This prompted a predictable, round of scorn from the Western press. France went so far as to say his statements represent a threat to public health. The New York Times—echoing the standard view of the AIDS Establishment—claimed, just hours after the Pope’s remarks, that he “deserves no credence when he distorts scientific findings about the value of condoms in slowing the spread of the AIDS virus.” However, Edward C. Green debunked that conventional wisdom, writing, “I am a liberal on social issues and it’s difficult to admit, but the Pope is indeed right. The best evidence we have shows that condoms do not work as an intervention intended to reduce HIV infection rates in Africa.” Green concluded that what “we see in fact is an association between greater condom use and higher infection rates.” We have many empirically documented examples of this phenomenon. In Uganda, for example, a state-of-the-art condom promotion program found that the intervention group of eighteen- to thirty-year-olds used more condoms but also reported having significantly more partners than the control group. In the final analysis, the intervention group was at higher risk than the control group, even though the former had higher condom use. These findings should prompt serious reconsideration of the dominant approach to HIV prevention advocated by the AIDS Establishment. They call into question how well these interventions have lived up to one of the most cherished principles and the first maxim in medicine and public health, “do no harm” (primum non nocere). This awareness also helps explain the AIDS Establishment’s reluctance to acknowledge the decisive contributions of abstinence and fidelity and to give them the emphasis they deserve.
To further study and confirm the existence of Risk Compensation, we have performed a Cross-sectional study to evaluate whether the belief that condoms are 100% effective can be indeed associated with sexual initiation among youth. Participants consisted of 8,643 male and female students, selected from both public and private schools in three different developing countries from Asia, Central and South America.
Students were asked about their knowledge of the risks of being infected with HIV and of getting pregnant if one has sex with condoms, in order to identify those believing that condoms are 100% effective. They also indicated whether they had ever had sexual relations.
The results that are pending publication show that there is reasonable empirical evidence to suggest that risk compensation exists in response to some messages about condom effectiveness. Results will be available at the web shown above when definitely published.
Conclusions
The issue of risk compensation raises further interesting questions: Might there be something flawed in the philosophical and cultural assumptions on which some public health interventions are based? Ideas, after all, have consequences. John Richens notes that demonstrating or precisely quantifying disinhibition in matters of sexual health is very difficult. But he has pleaded for a “stronger focus on interventions that can be shown to truly reshape individual’s willingness to expose themselves to the risks of HIV.” He has also pointed out that efforts to restrain behavior would confront entrenched forces within the culture, such as the “present climate of sexual freedom and the media portrayal of sex. It would raise suspicions that whoever was delivering the message was acting from a moral standpoint.” He has worried that scientific work in this area of risk compensation may be “misused” by religious or family oriented groups, but has also admitted that the concept remains “off-limits” in the public health community, as it is perceived as a threat by those with vested professional interests. There are condoms to be sold, new markets to be opened, grants to be awarded, prestigious articles to be published. The concept thus threatens many livelihoods as well as cherished values of modern Western culture, and we seriously need to confront these issues when trying to convey the right messages to the general population.
Public health authorities, the media, educators and parents are therefore invited to review how campaigns promoting condom use are being transmitted to youth and how messages could be more clearly conveyed in the future.
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