Response to Jack Bloom's comments on the Pope and Condoms

The DA leader in the Gauteng legislature, Jack Bloom, has written a statement defending the Pope's recent widely reported scepticism of condoms. Bloom's comments show a poor appreciation of AIDS science. His attempt to rescue the Pope is flawed.

By Nathan Geffen, TAC Treasurer

(This article was originally published on politicsweb on 3 April 2009.)

The DA leader in the Gauteng legislature, Jack Bloom, has written a statement defending the Pope's recent widely reported scepticism of condoms. Bloom's comments show a poor appreciation of AIDS science. His attempt to rescue the Pope is flawed.

Bloom claims that the Pope's comments are more subtle than the media has reported. He gives the full quotation as, "if the soul is lacking, if Africans do not help one another, the scourge cannot be resolved by distributing condoms; quite the contrary, we risk worsening the problem. The solution can only come through ... the humanisation of sexuality, in other words a spiritual and human renewal bringing a new way of behaving towards one another."

Other sources have reported the Pope's words differently and there appears to be some confusion about what precisely he said. Nevertheless, assuming Bloom's quotation is accurate, explicit in the Pope's statement is that condom distribution risks worsening the HIV epidemic; the media have not got it wrong. It is for this reason that numerous organisations including one of the world's leading medical journals, The Lancet, have criticised the Pope. The TAC released a statement criticising the Pope primarily because of our concern that what follows from the Pope's statement is opposition to sex education programmes in schools that includes information on and availability of condoms. Schools, after all, are one of the most important locations for AIDS prevention work.

Bloom concludes, "Condoms or no condoms, if we constantly reduce sex to biology rather than committed relationships, we will never change the risky behaviour that drives our AIDS epidemic."

The second part of this conclusion is correct. It is uncontroversial that risky behaviour drives the transmission of HIV. We need to try to change it. Promoting committed relationships is surely part of that. However, to argue as Bloom does that condoms are irrelevant (the only reasonable meaning of "condoms or no condoms") is dangerously wrong. If condom distribution were removed from AIDS prevention programmes the scale of the HIV epidemic would very likely be far worse.

Bloom compares the rise in HIV prevalence in Gauteng to the decline in HIV prevalence in Uganda and argues that the difference is that Gauteng concentrated on condom distribution while Uganda emphasised fidelity and abstention. He supports his argument by stating that the antenatal survey in Gauteng shows a rise in prevalence from 29.4% in 2000 to 30.3% in 2007, while in Uganda, HIV infection dropped from 18 to 6%. Bloom has dressed his opinion up with scientific arguments. But his facts are selective and his science is wrong.

It is extremely difficult to compare two very different geographical locations and draw conclusions about which of condom, abstinence or fidelity promotion was the key to success. This is why scientists prefer to draw conclusions from controlled experiments or properly analysed observational data - not from opinions about controversial and hazy facts. But let's nevertheless briefly look at Uganda and Gauteng.

Condom distribution coupled with increased condom use was very much a part of the Ugandan HIV programme during the period in which prevalence dropped substantially. It was coupled with intensive public education which promoted increased monogamy ("zero grazing") and delayed sexual debut. The programme was successful though not as much as is popularly believed. There are two additional reasons why Uganda's prevalence dropped:  it was probably overestimated in the first place and many people died of AIDS because they went untreated.

Uganda's prevention programme was not uniformly implemented and the evidence appears to show that different aspects of the programme were more effective at different times and in different places. A good summary of what happened in Uganda can be found in this article from The Lancet:

By contrast Gauteng, as with every other province, has failed to run a useful public education campaign on HIV prevention and more importantly has been subject to a conservative national policy not to make condoms available in schools. Also, Gauteng is not Uganda: culturally they are no more similar than, say, Britain and Russia. It is not clear that a Ugandan style public information campaign would work in Gauteng nor is it clear how such a campaign can be replicated there.

Rather than comparing Gauteng to Uganda we have to ask: What does the best available scientific evidence currently show? Several reputable sources provide essentially the same answer. For example, the AIDS Research Institute of the University of California, San Francisco, which examined prevention programmes implemented in US schools, stated:

An assessment of the peer-reviewed, published research reveals no evidence that abstinence- only programs delay sexual initiation or reduce STIs or pregnancy. By contrast, credible research clearly demonstrates that some comprehensive sex education, or 'abstinence-plus,' programs can achieve positive behavioral changes among young people and reduce STIs, and that these programs do not encourage young people to initiate sexual activity earlier or have more sexual partners.

Their analysis can be downloaded here (PDF). There is also some evidence showing that condom promotion and distribution has been successful at keeping HIV under control in Thailand and Brazil.

Bloom's position on condoms appears to be informed by his personal moral judgments. He says that "youths interviewed in one study ... thought it quite normal to have multiple sexual contacts" is "shocking". The reality is that a large proportion of youths in South Africa begin having sex at a young age and some of them have multiple partners. There are many complex reasons for this and there is no known practical intervention that is likely to change it soon. It is therefore important that sexually active youths have access to condoms and are taught what their benefits are.

It is worth reiterating that the scientific evidence is clear that condoms properly used are an effective way to reduce the risk of HIV transmission. A panel of 28 experts assembled by the US National Institutes of Health made this finding:

The Panel concluded that, based on a meta-analysis of published studies "always"users of the male condom significantly reduced the risk of HIV infection in men and women. These data provided strong evidence for the effectiveness of condoms in preventing HIV transmission in both men and women who engage in vaginal intercourse.

The report can be downloaded here (PDF)

We have just emerged from over a decade of an unscientific response to the HIV epidemic by the state. This cost at least three hundred thousand lives. Surely this has taught us how important it is that all political parties and their spokespersons base their views on how to alleviate the epidemic on the best available science.