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The global condom gap

Condoms are the single most effective technology to protect against sexual transmission of HIV/AIDS, a disease that killed up to 3.5 million people in 2003 alone and infected up to 5.8 million others.2 Unsafe sexual practices remain the dominant mode of HIV transmission in most regions of the world. In Asia, where an estimated 7.2 million adults and children are living with HIV, low condom use among sex workers and their clients accounts for a substantial proportion of new HIV infections.3 Widespread and consistent condom use has been shown to reduce the number of people infected with HIV enough to slow the spread of AIDS.4 Multilateral organizations such as the World Health Organization and the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommend condoms as an essential intervention against HIV.

Relative to their effectiveness at preventing HIV, however, condoms are a scarce and restricted commodity. The World Health Organization estimated in August 2003 that billions of condoms were needed to prevent the escalation of the AIDS epidemic in Asia, including more than 1 billion condoms in China alone.5 Globally, the gap between the number of condoms needed for HIV prevention and the number available was estimated in 2000 at anywhere from 15 to 18 billion condoms.6 In developing countries, many of which rely principally on international donors for condom supplies, only 950 million of the estimated 8 billion condoms needed to achieve a “significant reduction” in HIV infection—less than one eighth of those needed—were donated in 2000.7 The average international price of a male latex condom is U.S.$0.03 (three cents), including the costs of sampling, testing and shipping.8

In 2002, United Nations Population Fund Executive Director Thoraya Obaid warned that “[i]n all of the [HIV/AIDS]-affected countries, the supply of condoms is far short of what is needed.”9 Such supply gaps are accompanied by an equally dire scarcity of information. In its 2002 global AIDS report, UNAIDS stated that “[a]lmost everywhere, sexually active young people (especially young women) are denied information about condoms.”10

Condom shortages stem not only from resource constraints, but also from deliberate government policies that restrict condom manufacture, procurement, distribution, and information on their use. Such policies may limit distribution of condoms in public places, censor information about condoms in schools, regulate import of condoms manufactured abroad, or invest public funds in programs that make false or misleading claims about condoms.11 Many governments fail to streamline administrative requirements regarding condom storage, logistics and purchasing, creating the potential for wastage and inflated prices. Few have a national strategy or working group on reproductive health supplies that would ensure equal access to condoms, particularly among high-risk groups and people living in rural areas. Too often, governments fail to promote condoms and impart necessary skills and knowledge for fear that doing so will promote sexual activity or birth control.

Incomplete information about HIV/AIDS can both elevate HIV risk and fuel negative stereotypes about people living with the disease.In July 2002, a joint report of UNAIDS, WHO and the United Nations Children’s Fund (UNICEF) stated that “the vast majority” of people aged fifteen to twenty-four—an age group that accounts for 50 percent of new HIV infections worldwide—had “no idea how HIV/AIDS is transmitted or how to protect themselves from the disease.”12 UNICEF surveys of young women in eighteen countries found that significant percentages had at least one negative attitude towards people living with AIDS—including over 80 percent of respondents in the Philippines.13 Many people continue to think of HIV/AIDS as a disease of sex workers and gay men, a view too often associated with a low perception of broader HIV risk and a deep stigma against people living with AIDS. HIV prevention campaigns that censor information about condoms can heighten this risk.

Condoms and HIV/AIDS in the Philippines

Condoms have long been a flashpoint for controversy in the Philippines, a country that is nearly 85 percent Catholic and is heavily influenced in its AIDS policy by the Vatican. Since the early 1990s, the Catholic Bishops Conference of the Philippines (CBCP) has issued official statements vilifying condoms, campaigned against legislation that would expand condom access, and levied personal attacks against government officials who favor inclusion of condoms in HIV prevention programs.14 The secretary of health under former President Fidel Ramos, now Senator Juan Flavier, was denounced as an agent of Satan by the former archbishop of Manila, Jamie Cardinal Sin, for pursuing a bold strategy of condom promotion in the 1990s.15 At a public rally in 1994, the pro-life cardinal reportedly threatened to “tie a millstone around [Flavier’s] neck and drop him in the middle of Manila Bay.”16 When Flavier distributed condoms to journalists covering President Ramos’ 1992 trip to Thailand, conservative Senator Francisco Tatad accused him of promoting “promiscuity, lechery, adultery, and sexual immorality” and called for his resignation.17 As recently as 2001, Cardinal Sin issued a pastoral exhortation entitled “Subtle Attacks Against Family and Life,” in which he referred to “the naturally occurring minute pores present in all latex materials” and stated that “the condom corrupts and weakens people . . . destroys families and individuals . . . and spreads promiscuity.”18

A combination of widespread high-risk behaviors, low HIV/AIDS knowledge, and the presence of STDs that increase HIV vulnerability has led health experts to fear an HIV/AIDS “explosion” in the Philippines. In June 2002, the U.N. special envoy for HIV/AIDS in Asia, Dr. Nafis Sadik, warned that the Philippines had “huge explosion potential” given the presence of many known routes of HIV transmission such as low condom use among sex workers and increasing rates of adolescent sexual activity.19 This observation was echoed in September 2003 by Philippines Secretary of Health Manuel Dayrit, who noted that the presence of STDs such as chlamydia, gonorrhea and syphilis among Filipinos signaled that HIV could spread throughout the population unless swift measures were taken to prevent it.20

Surveys of sexual behavior in the Philippines reveal significant risk behaviors among surveyed populations, as well as lower than expected knowledge of how to prevent HIV infection. In 2002, freelance sex workers in the Philippines reported having an average of five sex partners per week and using condoms only 30 percent of the time.21 Nearly 40 percent said they did not know three correct ways of preventing HIV transmission.22 Reported signs of sexually transmitted infections other than HIV, which both increase HIV vulnerability and indicate HIV risk behavior, stood in 2002 at 24 percent of registered sex workers, 18 percent of freelance sex workers, and 7 percent of men who have sex with men.23

Despite these risk factors, the Philippines apparently still has an opportunity to avoid a generalized AIDS epidemic. Joint estimates of the Philippines Department of Health and WHO place the number of cases of HIV infection in the country at between 6,000 and 10,000 out of a population of approximately 84.6 million.24 This includes cases reported to the DOH’s HIV/AIDS Registry, which numbered 1,965 as of December 2003, and cases estimated to exist based on HIV testing in ten sites of four “high risk” populations: registered sex workers, freelance sex workers, men who have sex with men, and injection drug users.25 In 2003, a total of five sex workers and zero injection drug users and men who have sex with men tested HIV-positive in ten surveillance sites.26 Using a formula that estimated the percentage of high risk populations in the general population, the government estimated a minimum of 6,000 cases nationally, equivalent to approximately three cases for every one case reported to the HIV/AIDS Registry.

Numerous experts have questioned how the Philippines can have such a low HIV prevalence given the presence of numerous risk factors in the country. Possible explanations, none of which has been properly studied, include a low turnover of customers among sex workers, a comparatively low prevalence of STDs such as syphilis and herpes that increase risk of HIV infection, and a high circumcision rate among Filipino males which is thought by some reduce the chances of HIV transmission. Experts agree, however, that none of these factors provides an excuse for complacency in the face of a potentially explosive HIV/AIDS epidemic.27

It is a dangerous irony that the same health minister who warns of a possible HIV/AIDS outbreak in the Philippines refuses to support the public sector purchase of condoms for HIV prevention, even in the face of an unprecedented condom supply crisis. The Philippines Department of Health recommends that local government units “have ample supply of condoms” as part of an intensified HIV/AIDS education and information campaign.28 However, this same department relies almost exclusively for its condoms supplies on the United States, which announced in 2002 that it would be phasing out its shipments of free condoms to the Philippines.29

U.S.-funded condom programs are largely the product of previous administrations and pre-date the expansion of “abstinence until marriage” programs under President George W. Bush. Experts told Human Rights Watch that the combined influence of the Bush administration and the Vatican and the intransigence of the Philippine government could result in the introduction of U.S.-funded “abstinence until marriage” programs in the Philippines. Dr. Maria Elena F. Borromeo, country coordinator for UNAIDS in the Philippines, told Human Rights Watch, “There is a potential for abstinence-only education here. This is what the church is advocating, and if the church advocates for it, the government will follow. And the United States and the Philippines? They are of a feather.”30 Dr. Rhoderick Poblete, officer in charge of the Philippines National AIDS Council (PNAC), added that “abstinence-only fits the current Philippine policy, but I’m very scared of the impact.”31 He said that the country was experiencing a “downward trend in safe behaviors,” and that USAID resources were needed to leverage local governments to enact condom promotion ordinances. The fact that USAID was ending its contraceptive shipments without any national budget for condoms, he said, was a sign that abstinence-only “is happening, and it’s what the current leadership would like.”

The cornerstone of HIV prevention efforts in the Philippines is the 1998 AIDS Prevention and Control Act (the “AIDS Act”), hailed by the UNAIDS as a “best practice” in HIV prevention. Article 1 of the AIDS Act guarantees access to complete HIV/AIDS information in Philippine schools, health facilities, work places, pre-departure seminars for overseas workers, tourist destinations, and local communities.32 However, the AIDS Act contains other provisions that have the potential to restrict information about condoms. Section 4 of article 1 of the Act provides that HIV/AIDS education in schools “not be used as an excuse to propagate birth control or the sale or distribution of birth control devices” and “not utilize sexually explicit materials.”33 Although the Act mentions the use of “prophylactics” to prevent HIV, it does so only in the context of a provision requiring that all prophylactic sales include “literature on

Opposition to condoms in the Philippines, as in other countries, is by no means absolute among all Roman Catholics or even among church leaders. AIDS experts are quick to credit some religious leaders with supporting comprehensive HIV prevention efforts, and surveys show that a majority of Filipino Catholics do not consider religion in their family planning choices. However, the government’s receptiveness to the anti-condom animus of powerful bishops has fostered a policy environment that is both hostile to effective HIV prevention and conducive to misinformation about HIV/AIDS.

Condoms and the Vatican

In its opposition to condoms, the Catholic Bishops Conference of the Philippines closely adheres to the policy of the Vatican. Official Catholic teaching, as expressed in the Catechism of the Catholic Church, is silent on the use of condoms against HIV/AIDS. However, Catholic teaching opposes the use of condoms for artificial birth control, and many bishops’ conferences, Vatican officials, and theologians have interpreted this as an all-out ban on condom use for any purpose. The potentially lethal implications of this interpretation have divided Catholic ethicists between those who support condoms as a “lesser evil” than HIV infection,35— and those who fear that allowing any leeway for condom use will promote sexual promiscuity and ultimately lead to the acceptability of condoms for birth control. This latter position was articulated by the Catholic Bishops Conference of the Philippines in 1993 in its first pastoral letter on the AIDS epidemic.

4. The moral dimension of the problem of HIV/AIDS urges us to take a sharply negative view of the condom-distribution approach to the problem. We believe that this approach is simplistic and evasive. It leads to a false sense of complacency on the part of the State, creating an impression that an adequate solution has been arrived at. On the contrary, it simply evades and neglects the heart of the solution, namely, the formation of authentic sexual values.

5. Moreover, it seeks to escape the consequences of immoral behavior without intending to change the questionable behavior itself. The “safe-sex” proposal would be tantamount to condoning promiscuity and sexual permissiveness and to fostering indifference to the moral demand as long as negative social and pathological consequences can be avoided.

Furthermore, given the trend of the government’s family planning program, we have a well-founded anxiety that the drive to promote the acceptability of condom use for the prevention of HIV/AIDS infection is part of the drive to promote the acceptability of condom use for the contraception.36

This statement echoed a 1989 statement by Pope John Paul II, in which he condemned “morally illicit” means of HIV prevention as “only a palliative for deep troubles that call upon the responsibility of individuals and society” and “a pretext for a weakening that opens the road to moral degradation.”37

The Holy See, which represents the Vatican diplomatically and enjoys non-member state permanent observer status at the United Nations, has at various times sought to omit references to condoms from U.N. documents. At the June 2001 United Nations General Assembly Special Session (UNGASS) on HIV/AIDS, for example, the Holy See representative, Archbishop Javier Lozano Barragan, stated that the Vatican “has in no way changed its moral position” on the “use of condoms as a means of preventing HIV infection.”38 The following year, at the May 2002 UNGASS on Children, the Holy See joined the United States, Iran, Libya, Pakistan, and Sudan in endorsing sexual abstinence “both before and during marriage” as the only way to prevent HIV.39

Some Catholics hold that the issue of condoms and AIDS should be left to the discretion of public health officials, pastoral health workers, or simply the conscience of individual Catholics.40 And indeed, at the level of pastoral practice, many Catholic service providers advise their parishioners to use condoms against HIV.41 However, Catholic theologians who condone the use of condoms against AIDS risk swift censure from the Vatican. In 1988, Joseph CardinalRatzinger, at this writing the head of the Vatican’s Congregation for the Doctrine of Faith, criticized the U.S. Conference of Bishops for having supported condom use in their document, “The Many Faces of AIDS.”42 When South African bishop Kevin Dowling urged the use of condoms against HIV, the South African Bishops Conference responded with a statement condemning condom use, except in the case of couples in which only one partner is HIV-positive.43The mere observation of a softening within the church can generate a backlash, as in 2000 when two Catholic scholars concluded that some bishops support the use of condoms against HIV/AIDS.44 “There is a cold wind blowing from the Vatican at revisionists,” wrote Father Daniel Kroger, a Catholic ethicist in the Philippines, in February 2004.45

As in the United States, abstinence proponents from within the Catholic church hierarchy have at times made false scientific claims about condoms in order to buttress their moral arguments. In an October 2003 interview with the BBC, the head of the Vatican’s Pontifical Council for the Family, Alfonso Lopez Trujillo, stunned AIDS experts when he suggested that HIV can permeate microscopic pores in condoms. Calling the use of condoms “a form of Russian roulette,” Trujillo stated: “The AIDS virus is roughly 450 times smaller than the spermatozoon [spermatozoa]. The spermatozoon can easily pass through the ‘net’ that is formed by the condom.”46 Trujillo’s claim was not new. Since 2002, various bishops have claimed that HIV can permeate condoms, called for health warnings on condom packets, and cited anti-condom studies by the pro-“abstinence-only” Medical Institute for Sexual Health in the U.S. state of Texas.47 In fact, condoms are impermeable by the smallest STD pathogens, including HIV, and provide almost 100 percent protection against HIV when used correctly and consistently.48 In October 2003, the World Health Organization dismissed allegations of condom porosity as “totally wrong.”49

In June 2001, UNAIDS director Peter Piot publicly asked the Catholic church to stop opposing the use of condoms against AIDS, saying that “when priests preach against contraception, they are committing a serious mistake which is costing human lives.”50 The Vatican nevertheless used the occasion of World AIDS Day 2003 to defend its anti-condom stand, stating that HIV prevention campaigns should not be “based on policies that foster immoral and hedonistic lifestyles and behaviour, favouring the spread of the evil.”51

The United States: from condoms to abstinence

Historically the world’s leader in donating condoms to developing countries for HIV prevention, the United States has drastically reduced its condom commitment in the last decade52 and, simultaneously, has committed substantial resources to HIV prevention programs that give primary emphasis to sexual abstinence and marital fidelity. The five-year, U.S.$15 billion global AIDS package signed by President Bush in 2003 stipulates that 33 percent of assistance for HIV prevention be devoted to “abstinence until marriage” programs.53 Encouraging sexual abstinence has long been a staple of HIV prevention efforts, as evidenced by the so-called ABC—“Abstain,” “Be faithful,” “use Condoms”—approach adopted by the U.S. Agency for International Development.54 As implemented domestically by the United States, however, “abstinence-only” programs have been characterized by censorship and distortion of information about condoms, exaggeration of condom failure rates, and discriminatory messages against people, such as lesbians and gay men, who engage in sex outside heterosexual marriage.55

The potential exportation of abstinence-only programs to the developing world has caused considerable anxiety among AIDS service providers, particularly those associated with family planning.56 A recent USAID solicitation for funding proposals states that “programs [that] wish to include information about condoms in their programs may do so.”57 Yet these guidelines make no mention of condom uptake as an indication of program outcome or performance and, rather than taking steps to ensure accurate information about condoms, state that “applicants will not be required . . . to endorse, utilize or participate in a prevention method to which the organization has a religious or moral objection.”58 Statements by USAID officials minimizing the role of condoms in Uganda’s successful HIV prevention campaign in the 1990s suggest that USAID is focused primarily on the “A” and “B” of ABC.59 In August 2003, the cancellation of a multimillion-dollar contract for condom social marketing60 in Brazil added to growing fears of a shift in USAID policy away from condom promotion and toward strategies based on sexual abstinence.61

Pro-abstinence HIV/AIDS policy in the United States has evolved in a climate of increasing misinformation about condoms and official manipulation of scientific evidence.62 In 2002, a fact sheet on the effectiveness of condoms was removed from the website of the U.S. Centers for Disease Control and Prevention (CDC) and replaced by a new fact sheet which, while factually accurate, eliminated instructions on how to use a condom properly and evidence indicating that condom education does not encourage sex in young people.63Information on condom effectiveness was similarly altered on the website of USAID.64 The U.S. global AIDS bill cited above compels the president to report on the “impact that condom usage has upon the spread of HPV [human papillomavirus] in Sub-Saharan Africa,” a mandate that is clearly intended to undermine confidence in the use of condoms against HIV.65 Supporters of “abstinence until marriage” provisions, including U.S. Global AIDS Coordinator Randall Tobias, have relied on a misreading of successful HIV prevention efforts in Uganda, simplistically attributing decreases in HIV prevalence there to increased abstinence and fidelity.66 Since taking office in 2001, President Bush has appointed as high-level HIV/AIDS advisers physicians who deny the effectiveness condoms, such as former U.S. Representative Tom Coburn and Joe S. McIlhaney, Jr., president of the pro-“abstinence-only” Medical Institute for Sexual Health in Texas.67

Such overt anti-condom policies threaten to worsen what is already a strain on condom supplies as a result of restrictive U.S. international family planning policies. The Mexico City Policy or “global gag rule,” which bars any recipient of U.S. international family planning funds from using even private money to perform, counsel, or lobby for abortion, has reportedly led USAID to cancel or reduce condom shipments to grantees in up to twenty-nine developing countries.68 From July 2002 until late 2003, the United States refused to authorize funding for UNFPA based on unfounded allegations that the agency supported coercive abortion policies in China.69 In January 2003, a UNFPA official announced that the suspension of U.S. funding had resulted in a worsening of the Asian condom shortage.70

The United States has expanded its anti-condom agenda to the Asian continent, as evidenced by its efforts to delete endorsement of “consistent condom use” from the plan of action of the December 2002 Asian and Pacific Population Conference.71The director of a large USAID-funded HIV prevention program in the Philippines told Human Rights Watch that, in late 2003, she altered references to “sex workers” on her organization’s website in order to address USAID objections to that term. “There had been news about censoring USAID websites in 2003,” she said, “so we changed the term ‘sex workers’ to something else—‘vulnerable men and women,’ something to that effect. We just said, well, better to be safe than sorry.”72

Condoms, HIV/AIDS information and human rights

Human Rights Watch recognizes the freedom of all people to follow their conscience in deciding whether to support or oppose the use of condoms. However, the duty of governments to protect public health requires that they rely on scientifically accurate information to craft the most effective possible HIV/AIDS prevention measures. Moral objections to devices that also can be used for birth control are not an adequate basis upon which to condemn thousands to an otherwise preventable death in the absence of equally effective alternatives.

Although condoms are not 100 percent effective, broad objections to condoms as an HIV prevention strategy find no basis in science. Laboratory tests show that no STD pathogen, including HIV, can permeate an intact latex condom.73 Both the WHO and UNAIDS recommend the use of condoms against HIV, stating in August 2001 that “[t]he consistent use of male latex condoms significantly reduces the risk of HIV infection in men and women.”74 This statement followed an extensive review of condom effectiveness convened by the U.S. National Institutes of Health (NIH) in 2000, in which the combined analysis of several studies showed an 85 percent decrease in risk of HIV transmission among consistent condom users versus non-users.75 Studies of sero-discordant couples, in which one partner is infected with HIV and the other is not, show that, with consistent condom use, the HIV infection rate among uninfected partners is less than 1 percent per year.76 Condoms can also have some effect against HPV by hastening the regression of lesions in the cervix and on the penis and by speeding up clearance of the virus, according to two Dutch studies published in the International Journal of Cancer in December 2003.77 A 2003 UNAIDS-sponsored study estimated that factors such as breakage, slippage and improper use lead to condom ineffectiveness in approximately 10 percent of cases.78

International law recognizes the right to the highest attainable standard of health, which includes access to information and services necessary for physical and mental health. Article 12 of the International Covenant on Economic, Social and Cultural Rights (ICESCR) specifically obliges governments to take all necessary steps for the “prevention, treatment and control of epidemic . . . diseases,” such as HIV/AIDS.79 The Committee on Economic, Social and Cultural Rights, the U.N. body responsible for monitoring implementation of the ICESCR, has interpreted article 12 as requiring “the establishment of prevention and education programmes for behaviour-related health concerns such as sexually transmitted diseases, in particular HIV/AIDS.”80 In the context of “general legal obligations,” the committee notes:

States should refrain from limiting access to contraceptives and other means of maintaining sexual and reproductive health, from censoring, withholding or intentionally misrepresenting health-related information, including sexual education and information, as well as from preventing people’s participation in health-related matters. . . . States should also ensure that third parties do not limit people’s access to health-related information and services.81

According to the committee, the ICESCR does not only oblige governments to establish these programs “expeditiously and effectively”; it also prohibits them from “interfering directly or indirectly with the enjoyment of the right to health.”82 Policies that frustrate HIV prevention by limiting access to condoms and HIV/AIDS information fit this description.

Access to complete and accurate information about condoms and HIV/AIDS is recognized by article 19 of the International Covenant on Civil and Political rights (ICCPR), which guarantees the “freedom to seek, receive and impart information of all kinds, regardless of frontiers.”83 Parties to the ICCPR are obliged not only to refrain from censoring information, but to take active measures to give effect to this right.84 This is particularly true in the case of threats as serious as HIV/AIDS, a disease that has not only killed millions of people, but whose spread is facilitated precisely by lack of information and the inability to make informed choices about health. The Committee on Economic, Social and Cultural Rights has similarly stated that “information accessibility” is an essential element of the human right to health, noting that “education and access to information concerning the main health problems in the community, including methods of preventing and controlling them” are of “comparable priority” to the core obligations of the ICESCR.85

Access to HIV prevention services, including condoms, saves lives. The right to life is recognized by all major human rights treaties and, as interpreted by the U.N. Human Rights Committee, requires governments to take “positive measures” to increase life expectancy.86 These should include taking adequate steps to provide accessible information and services for HIV prevention (particularly to marginalized populations), taking steps to correct life-threatening misinformation provided by private actors, and ensuring that any publicly funded programs do not withhold life-saving technologies and information about them.

Human rights law further recognizes the right to nondiscrimination in access to information and health services, as in all other services.87 Women, sexual minorities and people living with AIDS, all of whom are protected from discrimination under international law, stand to suffer disproportionately from programs that discourage condom use and promote abstinence and fidelity as primary HIV prevention strategies. There is strong evidence that women are biologically more vulnerable to heterosexually transmitted HIV than men and thus stand a higher risk of HIV infection in environments where condom access is restricted.88 This includes married women, who need to be educated about condoms insofar as they cannot ensure their spouses’ fidelity. For lesbians and gay men, who cannot legally marry in most parts of the world, programs that promote sexual abstinence until marriage imply no option but lifetime abstinence, a misleading message when condoms provide a safe and effective method of HIV prevention.

The human rights to health, information, life, and non-discrimination are also recognized by specialized treaties such as the Convention on the Rights of the Child (CRC) and the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW).89 Non-binding interpretations of international law, such as the Office of the High Commissioner for Human Rights (OHCHR)/UNAIDS International Guidelines on HIV/AIDS and Human Rights and the Declaration of Commitment of the United Nations General Assembly Special Session (UNGASS) on HIV/AIDS, similarly support the right to complete information about HIV/AIDS. The guidelines recommend that “restrictions on the availability of preventive measures, such as condoms. . . . should be repealed,” while the Declaration of Commitment calls for “expanded access to essential commodities, such as male and female condoms.”90

2 Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO), AIDS Epidemic Update: December 2003, p. 3. The same report notes that over 40 million persons are living with HIV/AIDS worldwide.

3 WHO Western Pacific Regional Headquarters, “Asia Needs Billions of Condoms to Curb AIDS Threat,” August 18, 2003.

4 S.D. Pinkerton and P.R. Abramson, “Effectiveness of condoms in preventing HIV transmission,” Social Science and Medicine, vol. 44, no. 9 (May 1997), pp. 1303-1312.

5 WHO Western Pacific Regional Headquarters, “Asia Needs Billions of Condoms to Curb AIDS Threat.”

6 R. Gardner, R.D. Blackburn, and U.D. Upadhyay, Closing the Condom Gap: Population Reports, series H, no. 9 (Baltimore, Johns Hopkins University School of Public Health, Populations Information Program, 1999), pp. 3-5. Such estimates vary according to the methodology used to determine the number of condoms needed. This study did not take into account female condoms, which account for a very small percentage of the number of condoms produced and used each year.

7 N. Chaya and K. Amen with M. Fox, Condoms Count: Meeting the Need in the Era of HIV/AIDS (Washington: Population Action International, 2002), p.29; United Nations Population Fund (UNFPA), “Global Estimates of Contraceptive Commodities and Condoms for STI/HIV Prevention, 2000-2015.” UNFPA recognized that donors need not fill the entire gap, given the contribution of local governments and commercial sector purchase of condoms.

8 N. Chaya et al., Condoms Count, p. 6.

9 UNFPA, Reproductive Health Essentials: Securing the Supply (2002), p. 15.

10 UNAIDS, Report on the global HIV/AIDS epidemic: 2002 (Geneva: UNAIDS, 2002), p. 87.

11 See, e.g., N. Chaya et al., Condoms Count, pp. 14-15.

12 UNICEF, UNAIDS and WHO, Young People and HIV/AIDS: Opportunity in Crisis (2002), p. 13.

13 UNAIDS, Report on the global HIV/AIDS epidemic: 2002, p. 68, Figure 14.

14 Many of these actions are documented in E.K. Wilkinson, AIDS Failure Philippines (Germany: Book of Dreams Verlag, 2002).

15 A. McIntosh, “Philippines: Manila Health Minister an Unlikely Agent of Satan,” Reuters NewMedia, January 4, 1995.

16 E.K. Wilkinson, AIDS Failure Philippines, p. 204, citing an article by A.G. Romualdez, Jr. in Malaya, May 28, 2002.

17 Ibid., p. 59.

18 Jaime Cardinal L. Sin, Archbishop of Manila, “Subtle Attacks Against Family and Life: A Pastoral Exhortation on Family and Life Advocacy,” July 9, 2001, paras. 19, 22.

19 A.A. Araya, Jr., “Country still has ‘huge explosion potential’: HIV-AIDS spread ‘low and slow’ but RP warned against complacency,” June 24, 2002, (retrieved December 8, 2003).

20 J. Aning, “Philippines Health chief warns of AIDS epidemic,” Philippine Daily Inquirer, September 29, 2003.

21 “Status and Trends of HIV/AIDS in the Philippines,” p. 18, Table 8 and Figure 7.

22 Ibid., p. 16, Figure 6.

23 Ibid., p. 22, Figure 10.

24 National HIV/AIDS Sentinel Surveillance System, “Status and Trends of HIV/AIDS in the Philippines: The 2002 Technical Report of the National HIV/AIDS Sentinel Surveillance System,” p. 47; Human Rights Watch interview with Dr. Rhoderick Poblete, officer in charge, Philippine National AIDS Council, Quezon City, January 26, 2003.

25 HIV/AIDS Registry, “Monthly Update: National HIV Sentinal Surveillance System,” December 2003. The ten surveillance sites are the cities of Angeles, Baguio, Cagayan de Oro, Cebu, Davao, General Santos, Iloilo, Pasay, Quezon, and Zamboanga. As discussed below, registered sex workers are those who work in licensed entertainment establishments and are required to undergo regular STD screening, whereas freelance sex workers are based either in illegal brothels or the street.

26 Human Rights Watch interview with Dr. Rhoderick Poblete, Manila, January 26, 2004.

27 See, e.g., S. Mydans, “Low Rate of AIDS Virus in Philippines is a Puzzle,” The New York Times, April 20, 2003.

28 “Status and Trends of HIV/AIDS in the Philippines,” p. 49.

29 Y. Fuertes, “Last USAID shipment of condoms in November,” Inquirer News Service, September 4, 2002.

30 Human Rights Watch interview with Dr. Ma. Elena F. Borromeo, UNAIDS Country Coordinator, Manila, January 15, 2004.

31 Human Rights Watch interview with Dr. Rhoderick Poblete, January 26, 2004.

32 Republic Act 8504, Philippine AIDS Prevention and Control Act of 1998, art. 1 (“Education and Information”), implemented by rule 2.

33 Ibid., art. 1, sec. 4.

35 Most recently, Cardinal Godfried Daneels of Belgium told a Dutch talk show that a married woman might have the right to demand that her HIV-positive husband use condoms before she consents to having sex with him. See, e.g., Agence France-Presse (AFP), “Cardinal endorses condoms to counter AIDS,” January 14, 2004.

36 Catholic Bishops Conference of the Philippines, “In the Compassion of Jesus,” January 23, 1993.

37 J. Parmelee, “Pope Condemns Bias Against Victims of AIDS: Emotional Vatican Conference Struggles With Moral Conflict,” The Washington Post, November 16, 1989.

38 Quoted in D. Kroger, “Reproductive Health and Family Planning: Where are the Catholics?,” paper presented at the First Philippine National Conference on Reproductive and Sexual Health, January 15, 2004, p. 3. Barragan, who is also head of the Vatican’s Pontifical Council for Health Care Workers, reiterated this position in 2003 prior to a Vatican symposium on health care. He stated that condoms contribute to a “pan-sexual” society and that “prevention . . . is called chastity.” The 2003 Lexicon On Ambiguous and Colloquial Terms about Family Life and Ethical Questions issued by the Vatican’s Pontifical Council for the Family states that people who encourage condom use are running an “exercise in self-justification” and concealing evidence of condom ineffectiveness. The 900-page lexicon also states that homosexuality stems from an “unresolved psychological conflict,” and that citizens of countries that allow gay marriages have “profoundly disordered minds.” Index for Free Expression, “Vatican: Glossary of sexual terms has harsh words for gays,” (retrieved March 15, 2004).

39 D. Sanders, “Birth Control No Solution for AIDS, U.S. Argues,” The Globe and Mail, May 8, 2002. The Holy See has ratified the Convention on the Rights of the Child but, as of this writing, has never submitted a report to the Committee on the Rights of the Child, the U.N. body that monitors implementation of the convention.

40 See, e.g., D. Kroger, “Where are the Catholics?,” pp. 2, 9; J.F. Keenan with J.D. Fuller, L.S. Cahill and K. Kelly, eds., Catholic Ethicists on HIV/AIDS Prevention (Continuum International, 2000), pp. 21-29; Catholics for a Free Choice, Sex in the HIV/AIDS Era: A Guide for Catholics (Washington, DC: Catholics for a Free Choice, 2003).

41 See, e.g, N. Kristof, “Don’t Tell the Pope,” The New York Times, November 26, 2004.

42 Letter from Cardinal Ratzinger to Archbishop Pio Laghi, apostolic delegate to the United States, May 29, 1988, cited in Kroger, “Where are the Catholics?,” p. 3.

43 UN Office for the Coordination of Humanitarian Affairs, “AFRICA: Catholics and condoms – the debate continues,” IRIN News, December 5, 2002. Catholic Bishops Conferences throughout Sub-Saharan Africa have also remained steadfast in their objection to condoms, even in the face of pleas by government officials. See, e.g., AFP, “African Church rejects condom use despite high HIV infection rate,” October 9, 2003; “Kenya: Catholics Firm Over Condoms,” The Nation, March 25, 2003; UN Office for the Coordination of Humanitarian Affairs, “Tanzania: Clerics’ condom stand at odds with national policy,” IRIN News, March 19, 2002; Reuter’s, “Church opposes Zambia’s anti-AIDS campaign,” January 5, 2001.

44 See J.D. Fuller and J. F. Keenan, “Tolerant Signals: The Vatican’s new insights on condoms for H.I.V. prevention,” America, September 23, 2000; A. Bermudez, “Condom Claim ‘A Flat Lie,’ Says Bishop,” National Catholic Register, October 22-28, 2000.

45 Kroger, “Where are the Catholics?,” p. 4.

46 BBC News, “Vatican in HIV condom row,” (retrieved February 13, 2004).

47 AFP, “Catholic Cardinal suggests health warning on condom packets,” October 13, 2003; “Why the fuss about condoms?”, The Tablet, February 1, 2003; “Zambia: ‘Luo’s Condom Plan is Killing Our People’,” Africa News, May 8, 2002 (quoting the pastoral coordinator of the Catholic Archdiocese of Zambia, Fr. Evaristo Chungu, as saying, “Scientists themselves agree that condoms have been failing to prevent pregnancy, and as the head of the spermatozoa is 50 times as large as the less than one micro AIDS virus, no informed person would believe that the condom will be more than occasionally effective”).

48 See U.S. Centers for Disease Control and Prevention (CDC), “Fact Sheet for Public Health Personnel: Male Latex Condoms and Sexually Transmitted Diseases,” (retrieved April 15, 2004); six studies cited in R. Gardner et al., Closing the Condom Gap, p. 13; European Union Commission, “HIV/AIDS: European Research provides clear proof that HIV virus cannot pass through condoms,” Brussels, October 20, 2003; National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services, “Workshop Summary: Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease (STD) Prevention,” July 20, 2001, p. 7.

49 T. Rachman, “Cardinal’s Comments on AIDS and Condoms Draw Criticism from UN Health Agency,” Associated Press, October 10, 2003. See also, “Cardinal’s Statement ‘Could Contribute to Spread of HIV/AIDS,’ Warns UNFPA leader,” UNFPA press release, October 13, 2003.

50 AFP, “Church’s stand against contraception costs lives,” June 29, 2001.

51 The statement was delivered by Cardinal Barragan. See P. Pullella, “Vatican defends anti-condom stand on AIDS Day,” Reuters NewMedia, December 1, 2003.

52 The United States reduced its condom donations from nearly 800 million in the early 1990s to just over 200 million in 1999. United States Agency for International Development (USAID) Bureau for Global Health, Overview of Contraceptive & Condom Shipments, FY 2001 (Washington, D.C.: PHNI Project, September 2002), pp. 17-18; Donald G. McNeil, Jr., “Global War Against AIDS Runs Short of Vital Weapon: Donated Condoms,” The New York Times, October 9, 2002.

53 H.R. 1298, United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003, ss. 402(b)(3), 403(a). The Act does not specify a level of assistance for HIV prevention, but it caps such assistance at 20 percent of HIV/AIDS funds, or a maximum of U.S.$1 billion.

54 See, e.g., USAID Bureau for Global Health, “The ABCs of HIV Prevention,” August 2003; “USAID: HIV/AIDS and Condoms,” (retrieved July 10, 2003); Anne Peterson, “Fighting AIDS: The Faith-Based Solution,” The Washington Times, April 6, 2003.

55 See, e.g., Human Rights Watch, “Ignorance Only: HIV/AIDS, Human Rights and Federally Funded Abstinence-Only Programs in the United States: Texas: A Case Study,” Vol. 14, No. 5(G), September 2002, pp. 19-21, 23-26, 34-40.

56 See, e.g., “A Planned Parenthood Report on the Administration and Congress: The Bush Administration, The Global Gag Rule, and HIV/AIDS Funding,” June 2003, pp. 14-15.

57 USAID, “Annual Program Statement: HIV/AIDS Prevention Through Abstinence and Behavior Change for Youth,” November 26, 2003, p. 7.

58 Ibid., pp. 7, 13-15.

59 T. Carter, “Uganda leads by example on AIDS: Emphasis on abstinence and fidelity slashes infection rate,” The Washington Times, March 13, 2003 (quoting Anne Peterson, USAID Director of Global Health, as saying that “[c]ondoms . . . are better than nothing, but the core of Uganda’s success story is big A, big B and little c.” The Uganda experience is discussed briefly below.

60 Condom social marketing is an approach that uses private sector advertising and commercial distribution to make condoms more accessible. Social marketing has traditionally been at the center of USAID’s condom promotion efforts. See “USAID: HIV/AIDS and Condoms.”

61 The New York Times, “Misguided Faith on AIDS,” editorial, October 15, 2003.

62 This issue attracted considerable commentary throughout 2002 and 2003. See, e.g., Nicholas D. Kristof, “The Secret War on Condoms,” The New York Times, January 10, 2003; Marie Cocco, “White House Wages Stealth War on Condoms,” Newsday, November 14, 2002; Caryl Rivers, “In Age of AIDS, Condom Wars Take Deadly Toll,” Women’s eNews, December 10, 2003, (retrieved February 16, 2004); Art Buchwald, “The Trojan War,” The Washington Post, December 11, 2003.

63 Compare CDC, “Condoms and Their Use in Preventing HIV Infection and Other STDs” (September 1999), available at with CDC, “Male Latex Condoms and Sexually Transmitted Diseases” (2002), available at

64 Compare USAID, “The Effectiveness of Condoms in Preventing Sexually Transmitted Diseases,” (retrieved January 28, 2003) with USAID, “USAID: HIV/AIDS and Condoms,” above.

65 H.R. 1298, s. 101(b)(3)(W). Pro-abstinence advocates have long sought to disparage condoms by speculating about the link between condom usage and HPV, beginning with efforts by then-Rep. Tom Coburn to require that condom packages carry a cigarette-type warning that condoms offer “little or no protection” against HPV, some strains of which cause cervical cancer. Condom use is in fact associated with lower rates of cervical cancer and HPV-associated disease, though the precise effect of condoms in preventing HPV is unknown. CDC, “Male Latex Condoms and Sexually Transmitted Diseases” (2002).

66 See, e.g., H.R. 1298, s. 2(20)(C); Tina Rosenberg, “On Capitol Hill, Ideology Is Distorting an African AIDS Success,” The New York Times, April 28, 2003; Emily Wax, “Ugandans Say Facts, Not Abstinence, Will Win AIDS War,” The Washington Post, July 9, 2003. The Uganda experience owes itself to a wide range of interlocking factors, including high-level political leadership and widespread voluntary HIV testing and counseling, that cannot be reduced to one or two interventions. However, national-level survey data suggest that delays in sexual debut, a reduction in the number of sexual partners, and increases in condom use all played a part in lowering HIV risk in Uganda. See Susheela Singh, Jacqueline E. Darroch, and Akinrinola Bankole, “A, B and C in Uganda: The Roles of Abstinence, Monogamy and Condom Use in HIV Decline,” Occasional Report No. 9, The Alan Guttmacher Institute, December 2003; S. Cohen, “Flexible But Comprehensive: Developing Country HIV Prevention Efforts Show Promise,” The Guttmacher Report on Public Policy, October 2002.

67 Coburn, who is co-chair of the Presidential Advisory Council on HIV and AIDS (PACHA), has stated that “the American people [should] know the truth of condom ineffectiveness.” McIlhaney’s Medical Institute for Social Health, which promotes abstinence-only sex education messages, produced a comprehensive monograph on condoms stating that condoms do not make sex “safe enough” to warrant their promotion for STD prevention. See H. Boonstra, “Public Health Advocates Say Campaign to Disparage Condoms Threatens STD Prevention Efforts,” The Guttmacher Report on Public Policy, March 2003, p. 2.

68 The Global Gag Rule Impact Project, “Access Denied: U.S. Restrictions on International Family Planning: Executive Summary” (2003), p. 4. The global gag rule does not apply to international HIV/AIDS funding, as long as recipients do not integrate abortion services or counseling into their HIV/AIDS services. See Mike Allen, “Abortion Providers May Get AIDS Money,” The Washington Post, February 15, 2003.

69 The agency was vindicated by the United States’ own fact-finding mission, and funds are expected to be disbursed in 2004. The 1985 Kemp-Kasten law withholds U.S. foreign aid from any organization that, as determined by the President, “supports or participates in the management of a program of coercive abortion or involuntary sterilization.”

70 “UNFPA Says U.S. Funding Cut Worsens Asian Condom Shortage,” U.N. Wire, January 22, 2003.

71 See, e.g., V. Joshi, “US Stance on Abortion and Condom Use Rejected at Population Conference,” Associated Press, December 18, 2002.

72 Human Rights Watch interview with Dr. Carmina Aquino, director, PATH Foundation Philippines, Inc., January 19, 2004.

73 See CDC, “Fact Sheet for Public Health Personnel: Male Latex Condoms and Sexually Transmitted Diseases,”; six studies cited in R. Gardner et al., Closing the Condom Gap, p. 13; European Union Commission, “HIV/AIDS: European Research provides clear proof that HIV virus cannot pass through condoms,”; National Institutes of Allergy and Infectious Diseases, “Workshop Summary,” p. 7.

74 “Effectiveness of Condoms in Promoting Sexually Transmitted Infections Including HIV,” WHO and UNAIDS Information Note, August 15, 2001.

75 National Institute of Allergy and Infectious Diseases, “Workshop Summary,” July 20, 2001, p. 14. The report noted that available data are less complete for STIs other than HIV and gonorrhea, but that there was a “strong probability of condom effectiveness” against “discharge” diseases such as chlamydia and trichomoniasis, as well as diseases transmitted through “skin-to-skin” contact, such as genital herpes, syphilis, chancroid, and HPV. Tom Coburn, by then co-chair of PACHA, responded to the NIH study by issuing a press release headlined, “Condoms Do Not Prevent Most STDs” and praising the NIH report for exposing “the ‘safe’ sex myth for the lie that it is.” In its August 2001 information note, WHO and UNAIDS expressed concern about “misunderstandings about the difference between ‘lack of evidence of effectiveness’ and ‘lack of effectiveness’.” See H. Boonstra, “Public Health Advocates,” p. 2; WHO and UNAIDS, “Effectiveness of Condoms.”

76 WHO, “Effectiveness of Male Latex Condoms in Protecting Against Pregnancy and Sexually Transmitted Infections,” Fact Sheet No. 243, June 2000, (retrieved November 3, 2003).

77 C.J.A. Hogewoning et al., “Condom use promotes regression of cervical intraepithelial neoplasia and clearance of human papilloma virus: a randomised clinical trial,” International Journal of Cancer, vol. 107 (2003), pp. 811-816; M.C.G. Bleeker et al., “Condom use promotes regression of human papilloma virus-associated penile lesions in make sexual partners of women with cervical intraepithelial neoplasia,” International Journal of Cancer, vol. 107 (2003), pp. 804-810.

78 N. Hearst and S. Chen, “Condom Promotion for AIDS Prevention in the Developing World: Is it Working?,” May 26, 2003. See also, S.D. Pinkerton and P.R. Abramson, “Effectiveness of Condoms,” estimating ineffectiveness at 6 percent.

79 International Covenant on Economic, Social and Cultural Rights (ICESCR), adopted December 16, 1966, entered into force January 3, 1976, GA Res. 2200 (XXI), 21 UN GAOR, 21st Sess., Supp. No. 16, at 49, UN Doc. A/6316 (1966), art. 12.

80 Committee on Economic, Social and Cultural Rights (CESCR), The right to the highest attainable standard of health, para. 16.

81 Ibid., paras. 34-35.

82 Ibid., paras. 31, 33; see also, paras. 48, 50, describing what constitutes a “violation” of the right to health.

83 International Covenant on Civil and Political Rights (ICCPR), adopted December 16, 1966, entered into force March 23, 1976, GA Res. 2200 (XXI), 21 U.N. GAOR, 21st Sess., Supp. No. 16, U.N. Doc. A/6316 (1966), art. 19(2).

84 See ICCPR, art. 2(2), providing that “each State Party to the present Covenant undertakes to take the necessary steps, in accordance with its constitutional processes and with the provisions of the present Covenant, to adopt such laws or other measures as may be necessary to give effect to the rights recognized in the present Covenant.” State responsibility to give effect to the right to information is further elaborated in S. Coliver, ed., The Right to Know: Human Rights and access to reproductive health information (Article 19 and University of Pennsylvania Press, 1995), pp. 45-47.

85 Committee on Economic, Social and Cultural Rights (CESCR), The right to the highest attainable standard of health, para. 44(d).

86 Human Rights Committee (HRC), The right to life: HRC General comment 6 (16th Sess., 1982), para. 5.

87 See ICESCR, article 2(2), as well as CESCR, General comment 14, paras. 12(b), 18-19.

88 A number of determinants of this higher risk have been cited, including the large surface area of the vagina and cervix, the high concentration of HIV in the semen of an infected man, and the fact that many of the other STDs that increase HIV risk are asymptomatic in women, which may lead to their being untreated for longer periods. Girls and women may also face discriminatory barriers to treatment of STDs, such as needing permission of a husband or male relative for certain services. See, e.g., Global Campaign for Microbicides, “About Microbicides: Women and HIV Risk,” at (retrieved July 24, 2003); UNAIDS, “AIDS: Five years since ICPD—Emerging issues and challenges for women, young people and infants,” Geneva, 1998, p.11, also at gender/newsletter.pdf (retrieved July 22, 2003); and Population Information Program, Center for Communications Programs, The Johns Hopkins University Bloomberg School of Public Health, “Population Reports: Youth and HIV/AIDS,” vol. XXIX, no. 3, (Baltimore, MD, Fall 2001), p. 7.

89 Convention on the Rights of the Child (CRC), adopted by GA Res. 4/25 of November 20, 1989; entered into force September 2, 1990; GA Res. 44/25, annex, 44 U.N. GAOR Supp. No. 49, at 167, U.N. Doc. A/44/49 (1989); Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW), adopted by GA REs. 34/180 of December 18, 1979, entered into force September 3, 1981; GA Res. 34/180, 34 U.N. GAOR Supp. No. 46 at 193, U.N. Doc. A/34/46 (1981).

90 OHCHR and UNAIDS, HIV/AIDS and Human Rights: International Guidelines (September 23-25, 1996), guideline 6, para. 31(c); United Nations Special Session on HIV/AIDS, Declaration of Commitment on HIV/AIDS (June 27, 2001), para 52.

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