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Last Updated: Friday, 21 November, 2003, 11:09 GMT
Condoms and culture: Ask the experts
Condom promotion in Berlin

Our panel of experts answered your questions in a LIVE interactive forum.



  • Transcript


    Can the condom save the world?

    Used consistently and properly, latex condoms significantly reduce the risk of HIV transmission, but promoting them in some cultures is proving difficult.

    Getting people to use them means getting to the heart of their sexual behaviour - and encountering cultural issues ranging from expectations about sex to gender inequality and religious views on fidelity.

    Should prevention programmes seek to change cultures? How important are condoms? How much resistance is there to using them?

    Our panel included:

  • Catherine Campbell of the London School of Economics and author of "Letting them die: Why HIV/Aids prevention programmes fail" - a study of a mining community in South Africa where a programme providing free condoms and education had little impact.

  • Dr Ishwar S Gilada, founder of the Saheli project, a programme promoting peer education among sex workers. Originally based in Bombay, the approach is now being replicated across India and in Nepal and Pakistan.

  • Sister Ursula Sharpe, Programme Advisor, Kitovu Homecare, Orphan and Counselling Programme, southern Uganda. Sister Sharpe established the Catholic-based programme which emphasises changing sexual behaviour in its educational strategy. She has just returned to Ireland after 17 years in Uganda.



    Transcript


    Newshost:

    Hello and welcome to this BBC News Interactive forum. I'm Richard Black. Today we'll be discussing the role of the condom in the fight against Aids, as part of the BBC's special season on the disease.

    New UN figures released yesterday said that this year, more people have been infected with HIV than ever before. Yet there's ample evidence to suggest that used properly, condoms significantly reduce the transmission of the disease. But getting people to use them means getting to the heart of their sexual behaviour - and encountering cultural issues ranging from expectations about sex to gender inequality and religious views on fidelity. How important then is the condom? And should Aids prevention programmes try to change people's cultures and behaviour?

    I'm joined here in the studio by Dr Catherine Campbell, a social psychologist from the London School of Economics and author of the book "Letting them die - why HIV/Aids prevention programmes fail". On the line in Bombay is Dr Ishwar S Gilada, a leading Indian Aids campaigner and founder of the Saheli project, which educates sex workers in India. And on the line from Dublin we have Sister Ursula Sharpe, who has just returned from seventeen years in Uganda, where she set up the Catholic-based Kitovo Aids programme.

    Let's go straight to our first email. This comes from Keith in Canada and he says quite simple: Would you trust your life to a millimetre of latex?


    Dr Catherine Campbell:

    Well I think I'm going to throw a spanner in the works rather and say that in fact it's not so much condoms and culture that are at issue here but in fact the social context of health - the way in which in sexual health is determined by factors such as gender and poverty. So that I think that clearly it's the small piece of latex that's the end point but that what we need to focus on a lot more are the processes intervening.


    Newshost:

    Well we certainly will as we go through the programme. But just coming back to Keith's very simple point?


    Dr Catherine Campbell:

    Well of course I would - very definitely, 100%.


    Dr Ishwar S Gilada:

    I feel the condom is such a thing which can prevent unwanted births and unwanted death and that is a few millimetres of latex. So if something which is used as a life-saver then why not use it?


    Newshost:

    How about you Sister Ursula Shape?


    Sister Ursula Sharpe:

    No, I wouldn't trust it because it's not 100% effective.


    Newshost:

    But it seems to be about 80 - 90% effective from what we can deduce from the evidence.


    Sister Ursula Sharpe:

    I think if it's used properly, but in many, many instances it's not - for all sorts of reasons. Either maybe people have taken alcohol and they don't put it on properly; maybe people are very, very young and they just don't use it properly.


    Newshost:

    It's interesting that you've those points because that in fact is the point of our second e-mail which comes from F. Molina in Spain who says: Condoms are a danger, because people feel secure if they use them, whereas the failure rate is about 10%. They can help increase Aids, because this false security tends to increase sexual contact
    Sister Ursula Sharpe, is that something you'd agree with then?


    Sister Ursula Sharpe:

    Yes I would. I think it's very, very important that we look at what has been advocated now by the WHO and the UN - the ABC. That the ideal is abstinence but that may not be possible for everybody, then we look at behaviour and attitude change and as a last resort, the condom. I think it's terribly important that we give very factual information about these three areas.


    Newshost:

    Dr Ishwar S Gilada, if our correspondent, F. Molina in Spain is right, you're actually increasing the risk of the sex workers that you work with in Bombay by promoting condoms.


    Dr Ishwar S Gilada:

    No, basically condoms prevents 95% of the circumstances to get HIV or any STD. Even if we promote condoms openly, very widely, the risk is reduced by 95% but our use is not increased by 19 - 20 times. So it is rubbish to say that just because you're promoting to condoms, people are likely to use more and they will take more risks.


    Newshost:

    We've just had an e-mail come in from Giovanni Morvino in Edinburgh in the UK who asks: What is the average failure rate for a condom?


    Dr Catherine Campbell:

    Well I think the correspondent in India seems to have has fingers on that data, so possibly go back to him.


    Dr Ishwar S Gilada:

    The actual failure rate is between 1 - 2% and that depends on the quality of the condom. The other failure rate to 3 - 5% that is the failure in the proper uses of the condom.


    Newshost:

    Now is that when people are actually using condoms perfectly, when they know how to use them - that that figure of 3% or is that, if you like, a real world figure with real world accidents, real world problems?


    Dr Ishwar S Gilada:

    Earlier India used to have some condoms which were a non-lubricated, powdered condom and that had more breakage rates and again breakage depends on where it is a breakage. If the breakage is at the tip, then there is more risk. If the breakage is in the shaft or at the rim, there is hardly any risk.


    Newshost:

    Nevertheless the evidence is you'd say that the condoms do reduce people's chances of getting HIV and let me come on there to our next e-mail from Michael Fox, France who says: If the scientists and health experts are right, that condoms can protect us from catching Aids from sex, then isn't it a terrible sin for religious leaders to tell us a lie?

    I think the context of the question is that comments from senior Vatican officials a few weeks ago who actually said that the HIV virus could pass through holes in condoms so that therefore actually wearing them was no good, it could actually increase people's chances of contracting HIV. Sister Ursula Sharpe, let me put Michael Fox's point to you.


    Sister Ursula Sharpe:

    Well far be it from me to query anything that would come from the Vatican and perhaps they have information that I haven't had access to because I've been in Uganda all these years.


    Newshost:

    But in your own work in Uganda, you have been dealing with condoms haven't you - you haven't proscribed condoms?


    Sister Ursula Sharpe:

    What we have done in our programme, because we are a Catholic-based organisation, what we do is in teaching about abstinence, fidelity, behavioural change and condoms. I think it is very important that anybody dealing with education in HIV/Aids that we give the correct information and this we have done. There are many, many organisations, many shops selling condoms in Uganda.

    You have to remember that in Uganda we've had an incredible success story there. We've come from over 30% infection in the country down to 6% and yet our President Museveni, never once was there a condom campaign in Uganda. I guess he had his own reasons for that. But he made a regulation when he came to power in 1986 that every government employee would speak about HIV/Aids no matter what they were talking about. And I think that because of that consistent and constant education around the prevention of HIV/Aids that that is the reason that Uganda is the success story. But as I say, condoms are freely available but they have never been pushed, shall we say, by government.


    Newshost:

    So messages from political leaders are of course important but also messages from religious leaders, particularly where people are very religious in their own communities. Catherine Campbell in your own work in South Africa, did you find that adherence to religion could be a barrier to encouraging people to practise safe sex?


    Dr Catherine Campbell:

    I think that it certainly was. Firstly, in terms of all the misinformation and I feel very strongly that it is misinformation that comes from the Church around condoms. The other place where the Church has a lot to answer for is the role that it's played in perpetuating the stigmatisation of sex by saying that HIV is a punishment for bad behaviour and I think as a result it has stigmatised Aids - it's driven the disease underground and it has made particularly young people and women the most disempowered sectors of society - unwilling to be open about their sexuality to seek out information and to use condoms with confidence.


    Newshost:

    Well let me stay with the theme of religion and go to Dr Ishwar Gilada in India: Abdullah in South Africa says: There is only one solution to prevent Aids. No Sex until marriage and be faithful to your partner. "Adultery is an evil path," he says, quoting the Koran.
    Ishwar, how much do views like this affect what you're trying to do with sex workers in India?


    Dr Ishwar S Gilada:

    You can impose idealism on yourself - you can't impose idealism on others. For others you need to be practical. We all know that good behaviour is always good behaviour. So always we tell people to be good but if you can't be good, be careful and in any case be informed. HIV/Aids has not only one solution. There are several other things. Like in India we have been also using and promoting Kama Sutra and we are telling of one posture with multiple partners is worse - multiple postures with one partner is better than one with many partners.


    Newshost:

    Let me just pick you up on that. I'm a bit unclear on how promoting the Kama Sutra can restrain the spread of HIV?


    Dr Ishwar S Gilada:

    We discuss amongst a lot of males who are going to multiple sex partners, we ask them why do you change partners? They say we change our clothes, we change our men, we change our change our car - we change sometimes our partner. So by and large a lot of males need change. So we are providing them change by changing posture, by changing position - but don't change partners. That also can be one of the solutions.


    Newshost:

    We've had an e-mail from Ron in Australia who picks up on this point about men, he says: Men, most of all need re-educating. There is still a lot of selfishness without thought, and ignorance about their masculinity in many countries.
    Catherine Campbell would you agree with that?


    Dr Catherine Campbell:

    Yes, I would agree with that and I think that what we need to look at - and this is where I think that social context is very important, is that masculinity is associated very often with taking risks and also associated with hyper-sexual behaviour. But men are far more likely to get involved in over masculine behaviour when they lack power in other areas of their lives.


    Newshost:

    What do you mean by over masculine behaviour?


    Dr Catherine Campbell:

    Well over masculine behaviour including really taking more risks than they need to and having many partners in order to prove something to their peers rather than because necessarily they want to do so.


    Newshost:

    But in your own work did you find, for example, that asking men to wear a condom could be interpreted as some kind of threat to their masculinity?


    Dr Catherine Campbell:

    Absolutely, absolutely. Men again and again said that it's in the nature of man's desire to want pleasure - that flesh to flesh sex brings pleasure and that condoms undermine that and that in some sense as men we really don't care - we don't care about death, we don't worry, we don't fear illness, we don't fear death. Living out our masculinity involves enjoying life to the full in a kind of unfettered way.


    Newhost :

    Ishwar Gilada, you're targeting predominately female sex workers - shouldn't you be targeting their male clients?


    Dr Ishwar S Gilada:

    No, basically our idea is to target female sex workers, educate them and through them reach their clients. So we teach the sex workers client negotiation techniques of how to negotiate with the client for using safer sex. We give them multiple reasons to tell the client. It is not only the prevention of HIV/Aids or STD, it is also preventing some kind of behaviours which are totally weird. Sometimes males who are going to sex workers in the past and having STDs in the past, they become impotent. So we ask the male client if you don't want to be impotent, use condoms. If you don't want to produce a child then use a condom. If you want to enjoy sex for a longer time for the same money, then use a condom. We give them 10 - 12 reasons and sometimes they may pick up one reason or two reasons.


    Newshost:

    And does it work?


    Dr Ishwar S Gilada:

    It works - it has worked and currently the condom use in the red light area has gone up from less than 5% in 1991 to nearly 90% now.


    Newshost:

    So you're having success with that approach in the cultures that you work in. But one question we've just had in from James Faulkner in Bolton, UK which seems to go to the very heart of this issue. He writes: Given that contraception is forbidden in many cultures - obviously not yours in Bombay - is it time that we approach the fight against Aids differently? If not abstinence, then certainly promoting the importance of single partner relationships?


    Dr Ishwar S Gilada:

    We need to have multiple approaches. We are not saying that condoms is the only approach. We tell people that you can have abstinence when you are not supposed have a sexual relationship. But when you have a sexual relationship, be faithful to one partner.


    Newshost:

    Let me put the question to you Sister Ursula - the questioner basically says that given that contraception is forbidden in many cultures, is it time that we approach the fight against Aids differently - if not abstinence, then certainly promoting the importance of single-partner relationships?


    Sister Ursula Sharpe:

    I think it's very, very important that we look at the culture that we're in - as Catherine said, the social context. Yes, certainly in my experience, men in the rural areas particularly did not want to use condoms and a woman has no control over her body, so she is there for whenever the man wants to have sex. I don't agree with what Catherine said about the Church driving people with Aids underground, increasing the stigma. Because figures show that the caring of Aids patients that has been going on from Catholic programmes, Catholic workers, is much, much greater than any other denomination.

    My own experience is going into a home and caring for a person that has Aids. In the south of Uganda we have cared for over 35,000 people with Aids over these past 17 years. Now it makes a big difference if I'm going into that family and I'm showing the children in that family that I really do care. Then I form a relationship and begin to talk to the youth about HIV/Aids - about the prevention.


    Newshost:

    But you can care all you like, Ursula, you can look after sick people all you like. But if the Church is still telling them that condoms are bad then you're still going to have, are you not, an increase in HIV transmission?


    Sister Ursula Sharpe:

    Well I only know from Uganda and certainly the incidence has come down as everybody knows very, very dramatically. Granted, several people do use condoms but it's more in the urban areas, not so much in the rural areas. And I have seen over the years, a very big increase in people changing their behaviour.

    I think also the other thing that's terribly important is HIV testing. I've lived in a wider community where because thousands of people have died from Aids, people feel what has been termed as community depression. They say, but we're all infected, we're all going to die, so what's the point in changing our behaviour, let's enjoy life. Now bring HIV testing into that community and our experience is that more than 50% of the people that we have tested that thought they were HIV positive, are negative. Now you look at their behaviour and help them to look through counselling - that's how am I going to keep myself negative or if I'm positive, am I really going to go out and infect others. So I think that the culture and social context is terribly important.


    Newshost:

    Let's pick up on that point you've made about the social context. We've had an e-mail from Eddie Chisakulo in Zambia who asks: Sex in Africa for most women is regarded as a source for material gains (including sex in return for food). As long as we do not fight poverty, Aids will continue decimating the sub-Saharan people.

    He is picking up on this idea I guess that Sister Ursula Sharpe was espousing; it may be a question of changing other things in the culture other than sexual behaviour.


    Dr Catherine Campbell:

    I absolutely agree with that questioner. The link between Aids and poverty is a very strong one that has been proved again and again. However, as Sister Ursula has said, there have been some successes in Uganda which is a country which also experiences poverty. Aids needs to be fought at a range of levels; there needs to be poverty reduction and the empowerment of women. There needs to be safe sex messages going out. It's not a simple problem.


    Newshost:

    This is one of the questions that's often raised. If you take two countries which are roughly equal in terms of overall wealth, for example, Uganda and Botswana - Botswana if anything was probably richer a decade or so ago - and yet one has managed to control HIV transmission and in the other we're seeing rates soaring. What's the essential difference between the two?


    Dr Catherine Campbell:

    There are two differences. The first difference is that although Botswana seems to be a wealthy country, it is a very polarised country, there are very poor people and very wealthy people. Often the problem is income inequality rather than absolute income. Uganda is a society where's there's probably more equality and that Uganda is a society, for various reasons, where as already been said, there was some leadership and where the social preconditions made it possible for people at the grassroots and leadership to form a kind of unified collaboration to work together in fighting HIV/Aids. There was some kind of political will from the top and the bottom. And this is related in quite complicated ways to the history of Uganda. Uganda is an exceptional country that's had huge successes.


    Newshost:

    Let me pick up on an e-mail we've just had in from Bob Nickro in Gilligham in the UK: How can condom use best be conveyed to people in countries and cultures where the subject of sex is regarded as taboo and derogatory?


    Dr Ishwar S Gilada:

    In Indian ancient society, sex has been considered sacred. Sex has been worshipped. Sex has been portrayed in temples and everywhere. So sex has not been considered dirty in Hindu culture or ancient Indian culture.


    Newshost:

    It's an open subject anyway?


    Dr Ishwar S Gilada:

    It's an open subject. Secondly, what we want to portray about condoms is that it's a life-saver. If a helmet can be a life-saver to prevent head injury, if socks can be a life-saver in preventing a lot of injuries to the feet etc. then why can't condoms be projected as a life-saver?


    Newshost:

    Catherine in the projects you've been working with in South Africa, how have you dealt with this issue? How do you get people to even contemplate using condoms?


    Dr Catherine Campbell:

    This gets back to Sister Ursula's point in a way, of the contradiction between the role that the Church plays in caring for people and the contradiction of stigma? Certainly the communities I'm working in now which are deep rural communities in South Africa, the stigmatisation of Aids and sexuality is so bad that even in communities where up to 30% of the people are HIV positive, it's very common for people to say, I don't know anybody with HIV at all. What people do is they pass off their HIV as a more respectable disease - they say, I have tuberculosis or I have cancer etc. In those communities it's very, very difficult to promote condoms because people don't acknowledge that HIV/Aids exists in the first place and because of that high level of denial, there's no openness of people saying well we have a problem, we need health advice, we need health assistance.


    Newshost:

    It's a rather depressing picture your presenting there. I guess one thing that people watching this might say, is what if you can people young. We've had an e-mail on this very subject from Lyne Blais, Singapore, who says: I am planning in inform students aged 12 and 13 on Aids, including running a workshop putting a condom on a plastic penis. Some parents are worried that the children are too young. What do you think?


    Dr Catherine Campbell:

    I think one can never be too young. I think habits are very difficult to break and once a sexual habit has been established, it's much more difficult to break than to create good sexual habits from scratch. So I think that firstly one can never be too young and in South Africa they are already going into primary schools with children of 7 or 8. Secondly, I think a big myth which is very current internationally is the belief that some people have that if you talk to children about sex you're encouraging them to become sexually active. And in fact all the research says the exact opposite.


    Newshost:

    Sister Ursula Sharpe, I believe in your own work in Uganda, you would have children of 13 or 14 coming up to you and asking about condoms. How did you deal with this issue?


    Sister Ursula Sharpe:

    We had a lot of people trained in peer education and a huge network of volunteers. In the earlier days when I was involved, in the mid-80s, there was a huge stigma - I don't think that stigma was the Church at all. I think it was that people felt that they were infected with Aids because of witchcraft - I think every culture has taboos around sex. So in the earlier years it was very, very difficult because people were not coming forward. But as more and more people died we, - not just on the programme was with but many programmes throughout Uganda - became more and more involved with communities, huge numbers of volunteers came forth. We have over 700 volunteers - in all the organisations there seemed to be a spirit of volunteering.


    Newshost:

    But if you had children of 13 or 14 coming forward to you or some of these volunteers and saying, I want and need to find out about condoms because I may be having sex, what would you do? Would you say, yes, you do need to know about condom use and I'm going tell you as that's the reality of situation or would you say, you shouldn't be having sex, therefore, I'm not going to tell you?


    Sister Ursula Sharpe:

    I would never say to a child, you shouldn't do this. I think with children of any age, you sit with them and let them ask the questions and be very, very truthful in the answers that you give.


    Newshost:

    Many of the discussions, we've been having so far have assumed that condoms are available where and when you need them. But that's not always the case. We've had an e-mail in from Suzanne in the UK who says: Should condoms be made cheaper or even free to all?


    Dr Ishwar S Gilada:

    Condoms should be made free in the red light areas for the sex workers, they are making their living there. It should be priced at a very low price like it is in India through social marketing. Those people who are wealthier and high-flyers who want to buy coloured condoms or ribbed condoms, scented condoms etc, then they can be charged for this. So if you want luxury in condoms you will be charged and if you want just them as protection and a life-saver, they should not be charged or there should be at a subsidised price.


    Newshost:

    In your Saheli project I believe you're being supplied with condoms for free are you not?


    Dr Ishwar S Gilada:

    Yes, we are supplied free of charge from the Indian Government.


    Newshost:

    Just give me the roughly an idea of the numbers of condoms which you need for the 8,000 - 9,000 sex workers that you work with?


    Dr Ishwar S Gilada:

    We need and we get almost half a million condoms ever month for our projects where we cover 8,000 - 9,000 sex workers.


    Newshost:

    Let's change tack a little bit and talk about the messages about sex in the modern world. We had an e-mail from Burtukan, Ethiopian in the USA who says: We ought to understand and manage our sexuality. The world is bombarded with sex from every angle - from TV, the internet etc. We should shift our attention - there is a lot more to being human than just sex.

    Dr Catherine Campbell to put that to you: does that mean people actually become more sexually active when there's more talk about sex?


    Dr Catherine Campbell:

    I don't think so. Sex is a basic human instinct and it's a very pleasant and pleasurable thing and I think that people throughout the ages in all kinds of cultures and contexts have wanted to have it as often as they can. I think that in a way that's a bit of a side issue. I think that what we need to do, which Sister Ursula's already said, we need to strip the value judgements and moralising and social commentary that comes along with a lot of Aids talks and give very, very basic information. Aids can kill, particularly in countries where drugs aren't available. It can be prevented - it can be prevented through condoms. I think that that really is the message that needs to get through. The other debates obviously are relevant and interesting but I think they miss the point a little bit sometimes.


    Newshost:

    Ishwar Gilada, you were making the point that in classical Indian culture there has been lots of openness and lots of free talk about sex. It's been a subject that you can talk about. What do you think about the messages in the modern world? Do you think that all the talk about sex etc on tv is a good thing or a bad thing?


    Dr Ishwar S Gilada:

    No, there is nothing good or nothing bad; it depends on what kind of context you taking it. Basically, if sex is bad we are all born out of sex. We come to the world because of sex so sex is sacred, sex is very much acceptable everywhere. Though sex is not discussed openly in every Indian community, every Indian culture but within group to group, it is peer to peer, so it always a difference between age groups of different people. So we cannot discuss sex with our parents so easily like we can discuss it with our peers.


    Newshost:

    We've just received an e-mail from Vernon Chamberlain in the USA who asks: With the many new styles of condoms that add sensitivity for men and women, why do people still choose possible infection?


    Dr Catherine Campbell:

    Firstly, the need for pleasure dominates some people. I think that unprotected sex is often associated with intimacy, so people who lack intimacy or solid, good sustaining relationships in their lives in general are more likely to have unprotected sex. Then one can move onward from there to look at the broader social factors.


    Newshost:

    We have a final e-mail, this comes from Corrie Ludik, South Africa who says: Nothing will stop Aids until an effective vaccine is developed. Sex is too basic for humans to pin any hope on trying to control its various ways.


    Sister Ursula Sharpe:

    I think it will be wonderful if we had a vaccine, but we do have vaccines for polio and measles and other things and still everybody doesn't pick up on those vaccines and those diseases continue to spread.

    No, I can't agree with the questioner. I think it's a terrible disease. I have seen thousands of people die from it but I have seen the infection rate slow down dramatically in Uganda so I think it is possible. When people lose several members of their own families, they begin to think, they begin to take precautions, whether it's abstinence, whether it's condoms. A vaccine would be wonderful but I think people can change.


    Dr Catherine Campbell:

    I think this question is problematic because it sees HIV/Aids as a medical problem that should be solved by medical solutions. And I think that Aids is a microcosm of the way in which social contexts, social inequalities, the disempowerment of women, the disempowerment of young peoples impacts negatively on people's health. And if we have a vaccine for Aids there'll just be another epidemic, they'll just be another disease. In some sense what we have to do is look at the fact that many people live in social contexts which prevent them from being healthy and we need to address that rather than just having some kind of bio-medical solution that leaves the vastly unequal world and unhealthy societies in which many people live intact.


    Dr Ishwar S Gilada:

    There are actually two different things in this. One is whether a vaccine will be available or not. Secondly, Aids should not be seen in an isolated context. There has also been the disease of syphilis which was also a killer in earlier times but now is completely curable so maybe HIV/Aids can become curable in time. Maybe HIV/Aids can become preventable but there will some other diseases in the pipeline which will become sexually transmitted diseases. So one should not be so much focused on only a vaccine or only a cure. Cure can come, vaccine can come but there are other diseases which can come.

    Secondly, the sexually transmitted diseases are ping-pong infections. You catch one person, you treat that person, by that time that person may have infected other persons. So in ping-pong infections or in STDs, the cure is not going to be the solution of wiping out the disease from the whole earth. It is not going to be possible because all other STDs which are completely curable except herpes, they are not wiped there out, they are still there.


    Newshost:

    That's all we have time for today. My thanks to our three guests and thanks to all of you for taking part, those of you who watched and sent e-mails. Apologies to those of you whose e-mails we didn't have time for. If you'd like to know about Aids, visit our website at www.bbcnews.com/aids. But for now from me Richard Black and the rest of the news interactive team, goodbye.




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