For over twenty years I had the great privilege of being a member of the HIV/AIDS Advisory Committee of CAFOD (Catholic Fund for Overseas Development). This was a massive learning experience for me. CAFOD enabled me to visit some remarkable Home-Care projects in Uganda, Zimbabwe and Zambia. I was even invited, along with John Howson, to run two week-long courses on theological and pastoral issues related to HIV/AIDS in Harare and Bulawayo in Zimbabwe. Again, thanks to CAFOD, I was able to participate in theological conferences on HIV/AIDS here in the UK, as well as in Bangkok, New York and Dublin. All this had an enormous impact on me. Clearly, I felt an obligation to share what I had learnt so that people could become more aware of the terrible suffering and devastation being caused, especially in the developing world, by the AIDS pandemic. My eyes were opened to the fact that the rapid spread of HIV/AIDS in the developing world was linked to such fundamental issues as poverty and the second-class status of women in society. In my concluding essay in the groundbreaking work, Catholic Ethicists on HIV/AIDS Prevention, edited by James Keenan and others (Continuum, New York/London, 2000), I pointed out how that point had been made very forcefully by Teresa Okure:
An African theologian, Teresa Okure … startled her hearers by saying that there are at least two other viruses which are even more dangerous than HIV and which are the carriers enabling this virus to spread so rapidly among the most vulnerable in society.
One is a virus which affects people’s minds and their cultures – almost a form of human madness. It is the virus which makes people look on women as inferior to men – and it affects women as well as men. The other is a virus which is found mainly, though not exclusively, in the developed world. It is the virus of global injustice which is causing such terrible poverty in many parts of the developing world (p. 325).
Another eye-opening experience I had was to be invited to attend the 2004 International Conference of the Medical Missionaries of Mary (MMM) held in Nairobi. It was a gathering of sixty-two sisters, all medical professionals, including many doctors, who had been working at grass-roots in the caring for people living with HIV/AIDS. Their wealth of experience was mind-blowing. Moreover, as part of the preparation for this conference sisters were invited to contribute to an e-forum based on various practical questions. The question which drew the most impassioned responses was ‘What puts fire in your bellies?’ I am grateful to the MMM sisters for permission to quote from this e-forum in the article which follows.
I naturally felt obliged to share my experience of HIV/AIDS in my moral theology teaching at both Heythrop College in London and Liverpool Hope University. In addition, sharing my experience was the main motivation behind a number of articles on HIV/AIDS, as well as a major book on HIV/AIDS. Sadly the publishers of my book insisted that it should not be restricted to HIV/AIDS (‘people would not be interested in that topic’). Hence, it covered the much wider field of sexual ethics, appearing under the title, New Directions in Sexual Ethics: Moral Theology and the Challenge of AIDS (Geoffrey Chapman, London, 1998).
All who have been directly involved in the field of HIV/AIDS know that, if prevention is to be tackled effectively, it needs a fully comprehensive approach. The provision of condoms can be part of that strategy in some circumstances but its role is often massively exaggerated by the popular media. The article which follows tries to put the issue of condoms into this much wider comprehensive context. Even Benedict XVI recognised this in a very cautious and somewhat ambiguous way in his much-publicised comment in his book, Light of the World (CTS, London, 2010).
I am very grateful to Christine Allen and her Progressio staff for encouraging me to write this article and also to Ann Smith of CAFOD for her advice. Gill Patterson also kindly offered me helpful advice. This article has not been published elsewhere.
Introduction
After a number of AIDS-related visits to Africa and Asia I feel deeply affected by the human tragedy of HIV and AIDS, especially in the developing world and particularly regarding the situation of many women and how they are treated as second-class citizens. In fact, the inferior status of women in Africa was recognised as a major concern at the Second African Synod of Bishops in Rome in October 2009, thanks to the strong and courageous interventions of many of the twenty-five women invited to participate.
One very privileged experience was to be invited as theological consultant to a week’s conference in Nairobi in 2004 with Medical Missionary of Mary (MMM) Sisters from across the world, all involved with people living with HIV and AIDS. The sixty-two MMM participants at Nairobi were doctors, nurses, pharmacists and hospital administrators working in the field of HIV and AIDS in Angola, Benin Republic, Brazil, Ethiopia, Honduras, Ireland, Kenya, Malawi, Rwanda, Tanzania, Uganda and USA.
To prepare for the meeting they ran an e-forum to let each sister share her experience of the pandemic and how it had touched her personally. The e-mail replies came pouring in. They were deeply moving and showed how profoundly the sisters shared the pain of those for whom they were helping to care. In answer to the question, ‘What puts you fire in your belly?’, some replies were very revealing:
I get angry when I see the poverty of the people, especially women and girls. They have to keep working even when they are sick. This leaves them even more vulnerable to infection.
The injustices and fear women face on a daily basis – and little opportunity or ‘safe place’ to share this and find any support/solace.
Women abandoned, put out of their home and left penniless. Who will speak for them or help them to get their rights? Orphan children struggling on their own – and in the end exploited and abused. Sexual abuse of children. teenagers, orphans and a legal system which fails them. Physical abuse of children – within their own families.
This ‘fire in their bellies’ prompted some of the sisters to get involved with women who had become sex workers, due to the enormous pressures on them:
The Medical Director asked us to do something about the 700 women in the sex-trade. We contacted them indirectly. It took almost three months before the first women came. Six months later we had 48 registered clients. Today we follow about 300 women ‘in distress’. We have a small group of young rape victims who are not in prostitution, another small group of widows who are occasionally in prostitution and about 250 women who are single mothers and engaged in prostitution. Our women are very poor, mostly orphans. 40% have had virtually no education.
The sisters also shared how their faith sustained them. The psalm verse, ‘The Lord is close to the broken-hearted’ gave them great comfort. They quoted lines from the psalms which gave expression to their cries of anger and desperation to God – almost feeling abandoned – like Jesus on the Cross – ‘Jesus falling under the weight of the cross … he didn’t stay down … gives me courage for myself, a hope and courage I can pass on to others’. A final word from one of the sisters captures the pain they shared: ‘Sometimes I feel so angry, so inadequate, so frustrated, I want to scream.’
Being women themselves, the Sisters could see how women bear the brunt of the AIDS pandemic. Many were angered by the Church’s attitude to women:
I want the Church to show concern and compassion for the women caught up in the tragedy of AIDS. I would like to feel that the Church understands the powerlessness of women, how they are looked on as ‘the guilty ones’. Many women have ‘remained faithful’, – but now have AIDS and, after the death of their husbands care for their HIV-positive children. The older women care for their grandchildren and suffer deeply from poverty and from the abuse of their families. Can the Church show that it has heard the cry of these women, will stand by them and seek for justice for them?
I saw for myself the tragic reality the sisters are confronting on a daily basis on my various visits to Zambia, Zimbabwe and the huge Kibera slum on the outskirts of Nairobi in Kenya. Many husbands have to live most of the year in very dehumanising work-place dormitory accommodation. Overcome by loneliness, some find that the only way to survive is by setting up a second home (and family) with another woman. Others may forego that but find solace with a woman (lone-parent or widow) who has been forced into the sex industry to feed and support her children. If HIV-infection occurs through these arrangements, the wife at home might eventually find herself HIV-positive despite her being totally faithful to her husband. She might also eventually find herself a widow, after having nursed her husband when he came back home to die. There is also the tragic possibility that she might even have infected her own children. I was told of a whole variety of other dehumanising situations during my various visits – children forced to have sex with their teacher or examiner to get their grades, young girls responsible for child-headed families having no alternative but to seek help from an exploitative ‘sugar daddy’, widows and orphans reduced to being virtual slaves by the relatives of their deceased husband or father. In recent years, antiretrovirals, when available, have reduced somewhat the number of AIDS-related deaths.
Ann Smith, HIV CAFOD’s former Corporate Strategist, echoes the experience and feelings of the sisters very powerfully:
Too often, behaviour change is viewed through a Western, ‘developed’ world perspective which assumes that autonomous individuals make informed choices based on in-depth understanding of the facts. One of the erroneous assumptions is that everyone wants to be sexually active from an early age; another is that anyone sexually active outside marriage must be promiscuous. These ignore the fact that for many in the developing world sex is often the only commodity people have to exchange for food, school fees, exam results, employment or survival itself in situations of violence. There are immense social and cultural pressures on men and women to conform to accepted stereotypes; there are economic pressures that result in the break-up of families as migrant workers spend months on end far from their spouse and family support, plunged into unbearably harsh working and living conditions by exploitative local or multi-national employers. Nor is the spread of HIV always linked to promiscuity. Most HIV-women worldwide are infected by the person they considered to be their monogamous, lifelong partner (The Tablet, 25 September 2004, pp. 8-9).
Despite the awful inhumanity of this whole scene, the miracle is that so much goodness, self-sacrifice and moral heroism is found in the midst of it all. I constantly felt humbled by the commitment and dedication of most of the people I met, many of them HIV-positive themselves. I am reminded of something I wrote many years ago:
Moral theology is not meant to condemn the plant emerging from the seed simply because it does not live up to the promise of the idealised picture on the packet. Rather it appreciates the growth that occurs. Sometimes what might look like a puny and undeveloped plant might, in fact, be a miracle of growth, given the adverse conditions under which it has had to struggle (From a Parish Base, p. 109).
Writing about the virtue of mercy James Keenan remarks:
‘Inasmuch as mercy is the willingness to enter into the chaos of another so as to respond to the others, justice thickened by mercy insists on taking into account the chaos of the most marginalized’ (‘What does Virtue Ethics Bring to Genetics?’ in Lisa Sowle Cahill edit., Genetics, Theology and Ethics, Herder & Herder, New York, 2005, p. 104).
In the same volume Hasna Begum makes a similar comment:
‘Mere rational thinking, in the absence of direct experience of situations unique to poor countries, cannot possibly comprehend them in their uniqueness’ (Genetics, Ethics, Theology: A Response from the Developing World in Cahill, op. cit., p. 182).
I will never forget a young woman I met in the Philippines. Feeling worthless after having been abused by her father, when the responsibility for all the family (including her young siblings) fell on her as eldest, she found that the only way she could cope financially was to sacrifice herself for their sake by supporting them through becoming a sex worker. She was already HIV-positive by the time I met her and was working as a carer in a Church-sponsored HIV-hospice. Despite all the ambiguity in her life, as she shared her experiences with me, I was reminded of the words of Jesus, ‘Greater love …’. The following chapter, Maria’s Story, gives a fuller account of this remarkable woman.
Not only is it too facile to think in categories of ‘the lesser evil’ or being ‘excused from sin’ when talking about people’s courageous and self-sacrificing decisions in such dehumanising and freedom-diminishing situations. It can be deeply offensive to them and is lacking in respect for the love which may inspire their decision. In the circumstances their decision may well be awe-inspiring.
Pastoral compassion calls for an appreciation of the complexity of the whole issue of HIV-prevention and of the kind of world in which most people affected by HIV have to live their lives. In another article, James Keenan emphasizes the fact that most people affected by HIV live in ‘very unstable environments’ (cf. ‘Four of the Tasks for Theological Ethics in a Time of HIV/AIDS’, in Concilium, 2007/3, pp. 64-74). Any comprehensive approach to HIV-prevention will need to look at the root causes of such unstable environments. For the most part these causes lie almost entirely outside the direct control of the individuals affected.
People today are becoming increasingly aware of the interconnectedness of the lives of everyone. The roots of this interconnectedness go so deep that the social, economic and even cultural pressures which can so massively diminish some people’s freedom of choice may be linked to the very structures, institutions and assumptions of what people presume to call ‘the free world’. One person’s freedom can so often entail another’s captivity. As mentioned in the introduction to this article, the Nigerian theologian, Teresa Okure, insists that two other ‘viruses’ play a major role in HIV-infection – the ‘prejudice virus’ which sees women as inferior to men; and the ‘global injustice virus’ which is one of the root causes of such dehumanising poverty in many parts of the developing world.
A Comprehensive HIV Prevention Strategy
One of the most fully comprehensive approaches to HIV-prevention was that presented to the 2004 international AIDS Conference at Bangkok by CAFOD’s HIV specialist workers. Entitled ‘HIV Prevention from the Perspective of a Faith-Based Development Agency’, it won widespread approval from delegates.
The CAFOD presentation makes very effective use of the ‘problem tree’ model for analysing the HIV and AIDS pandemic. The tree’s branches and leaves represent the impact of HIV-infection – personal consequences such as sickness, death, trauma, bereavement, stigma, discrimination and increased poverty; and also social consequences such as increased demands on health services, loss of economic productivity, increased burden of care and lost educational opportunities, especially for women and girls. The roots of the tree represent the causes of HIV-infection. These are the factors which lead to people becoming HIV-infected. Some of these roots are more visible – the kinds of activity which put individuals at risk of infection. Other roots lie at a much deeper level and are less visible – factors increasing personal vulnerability (sexualhealth ignorance, loneliness, peer pressure, low self-esteem, violence and lack of education) or social vulnerability (poverty and its root causes, armed conflict, cultural and religious traditions which put people at risk or instil discriminatory or judgemental attitudes).
To be truly comprehensive a HIV prevention strategy needs to aim at mitigating the impact, and decreasing the vulnerability, as well as reducing the immediate risks. With regard to reducing the risks from sexual transmission, people need to have full and accurate information on the effectiveness and limitations of all means of reducing risk, so that they can make the choices that are possible in their specific circumstances. Initiatives that promote only a single option – whatever that option – are both ineffective and a denial of people’s rights to make fully informed choices.
Stigma is a major factor to be combated in any comprehensive HIV-prevention strategy. Since religious attitudes can be part of the problem, Christian Churches and other faiths have a special responsibility to tackle the roots of such stigma. Gillian Paterson insists on this very forcefully in her pamphlet, ‘Stigma in the context of development: A Christian response to the HIV pandemic’, Progressio Comment 2009.
Theology is about trying to make sense of how the God of faith is God-with-us in human history and fleshly reality. To be faithful to this task, theological reflection on living with HIV and AIDS must always be grounded in an honest and truthful analysis of the key human realities involved. Too often, faith-based discourse on HIV prevention has lacked a sense of HIV literacy; similarly, much criticism of faith-based approaches has lacked a faith-literacy, misunderstanding or misinterpreting the core values and insights which should in fact unite all who strive to halt the spread of HIV and AIDS. During my various visits, I was struck by the importance of faith in many of those living with HIV. Moreover, it seemed to be a major motivating force behind their personal involvement in community-based, home-care HIV and AIDS projects. I found the same to be true among those providing financial support in my own community back in St Basil & All Saints parish.
The Place of Condom usage within a comprehensive HIV Prevention Programme One of the MMM sisters referred to earlier, a medical doctor, wrote: ‘The official teaching of the Church condemns the use of condoms and this is killing our people.’
Her comment represented the feelings of many of the sisters. However, neither she nor her companions were suggesting that condoms were the only or even the main solution to the HIV and AIDS pandemic which was wreaking such havoc in people’s lives and thus causing such anguish to the sisters themselves. She was simply putting into words their conviction that an absolute prohibition of condoms ran counter to what they could see was urgently needed in some situations and did not ring true to the compassion of the Christ they loved and served in their AIDS ministry.
The original purpose of the condom was to prevent conception. It was seen as a more or less effective means of contraception. However, with the advent of HIV-infection a totally different purpose for the condom appeared on the scene. This was its ability to act as a barrier to prevent transmission of the HIV-virus. In the days when HIV-infection was virtually a ‘death sentence’, the condom was seen as a form of life-protection rather than life-prevention. More recently antiretrovirals, where available and in conditions favourable for effective use, have reduced the level of AIDS-related deaths. When antiretrovirals are being used, condoms can still have a health-protection role, even though antiretrovirals themselves can also help in reducing the risk of transmitting the virus.
Obviously, condoms protect health only insofar as they are effective barriers to HIV-infection. Consequently, there are morally significant questions to be faced on this level. As a barrier to HIV-infection, the effectiveness of condoms is open to scientific investigation and will depend on the answer to such questions as: (1) given a good quality condom, how effective is it as a barrier to HIV-infection? (2) what about the additional factor of ‘user failure’? (3) how ‘user friendly’ is it? (4) what safeguards are built in to check the quality of condoms?
The key question of how effective is a condom as a barrier to HIV-infection is tackled in a major US health report published in 2001 – National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services, Scientific evidence on condom effectiveness for sexually transmitted disease (STD) prevention, 20 July 2001. In the light of this research, James Keenan SJ has noted that HIV is a very inefficiently transmitted infection compared to other sexually transmitted diseases. For instance, sixty to eighty per cent of women are infected as a result of a single exposure to gonorrhoea, whereas only 0.1-0.2 per cent of women are infected after a single exposure to HIV. In fact, as Keenan noted, using a condom reduces the already low transmission rate of HIV by eighty-five per cent. Consequently, in the light of this largest 2001 analysis of published peer-reviewed studies on condom effectiveness, Keenan is prepared to state very confidently: ‘The conclusion is clear: condoms are not perfect, but for those who choose (or are forced into) sexual contact, significant protection is afforded by this method’ (James Keenan, ‘Four of the Tasks for Theological Ethics in a Time of HIV/AIDS’, in Concilium, 2007/3, p. 182).
Presuming that the research data given in the above survey takes account of ‘user failure’ and ‘user-friendliness’, current research would seem to indicate that, provided adequate quality control is in place, condoms are a highly, though not completely, effective means for reducing the risk of HIV-infection.
Although it is commonly assumed that ‘Catholic teaching’ does not permit the use of condoms as a method of protection from HIV-infection, there is, in fact, no ‘official’ teaching on the use of condoms in the context of HIV. In fact, the use of condoms is not actually mentioned by Paul VI in his 1968 encyclical, Humanae Vitae. What is forbidden by the Pope is ‘any action, which either before, at the moment of, or after sexual intercourse, is specifically intended to prevent procreation – whether as an end or as a means’ (no. 14).
Most commentators agree that in the above passage from n.14 the Pope was mainly, though not exclusively, talking about using ‘the pill’ with the deliberate intention of preventing conception. However, he makes it quite clear that he is not condemning using ‘the pill’ for a therapeutic purpose even though it might indirectly prevent conception:
The Church in no way regards as unlawful therapeutic means considered necessary to cure organic diseases, even though they also have a contraceptive effect, and this is foreseen – provided that this contraceptive effect is not directly intended for any motive whatsoever (no.15).
At the time of Humanae Vitae, the condom was not seen to have any therapeutic use. Its only purpose seemed to be as a form of contraception; and to intend contraception, either as an end or as a means, was forbidden by Paul VI’s encyclical.
The advent of HIV-infection some years after Humanae Vitae gave condom-use a new purpose and meaning i.e. its ability to act as a barrier preventing HIV transmission. This new situation means that there can also be a quasi-therapeutic use for the condom i.e. therapeutic in sense of infection-preventing. Although not a curative use, when it is directly intended as a barrier to HIV-transmission, it can truly be described as ‘safeguarding health’ and even ‘saving life’.
Hence, it could be argued that, if Humanae Vitae was being written today, the paragraph quoted above could legitimately be interpreted as meaning that the Church in no way regards as unlawful using condoms with the explicit intention of preventing HIV infection – even though condoms also have a contraceptive effect, and this is foreseen – provided that this contraceptive effect is not directly intended for any motive whatsoever.
Some may argue that the condom is not a ‘necessary therapeutic means’ since there is always the possibility of a couple abstaining from intercourse. Vatican II, more in touch with the reality of people’s lives, warns against that line of action: ‘When the intimacy of married life is broken off, the value of fidelity can frequently be at risk and the value of children can be undermined’ (Gaudium et Spes, no. 51). Enforced total abstinence fails to respect the role of sexual intimacy in a couple’s loving relationship which the same Vatican II document describes in relational terms as ‘mutual self-giving … welling up from the fountain of divine love’ (cf. no. 48 and 49). A couple bound together by such love will want to do what they can to avoid their love-making being health-threatening, possibly even life-threatening. To do otherwise would be to go against nature i.e. the nature of their married love. Hence, when one or both of them are already HIV-positive, their natural instinct to safeguard health might lead them to use a condom rather than threaten their love and fidelity by permanent abstinence.
In such situations a number of cardinals and bishops have accepted condom-use for HIV-prevention as a way to protect health and even life itself. To give but one instance, in 2004 Cardinal Danneels stated on Dutch TV:
For one who does not want or cannot follow this path (of chastity and faithfulness) and who opts to engage in unsafe sexual behaviour, it is morally justifiable to use a condom … Other cardinals and bishops all over the world share this perspective … This comes down to protecting yourself in a preventive manner against a disease or death. It cannot be entirely morally judged in the same manner as a pure method of birth control.
Shortly after this, Cardinal Murphy O’Connor stated his agreement with Cardinal Danneels’s position (cf. The Independent, 26 July 2004). Benedict XVI’s reply to Peter Seewald’s question, ‘Are you saying, then, that the Catholic Church is actually not opposed in principle to the use of condoms?’ hit the headlines, even though its precise meaning was unclear:
She of course does not regard it as a real or moral solution, but, in this or that case, there can be nonetheless, in the intention of reducing the risk of infection, a first step in a movement toward a different way, a more human way of living sexuality (Light of the World: Conversation with Peter Seewald, CTS, London, 2010, p. 119).
In the above analysis of the teaching of Humanae Vitae, I have refrained from mentioning that the adequacy of this authoritative but non-infallible teaching on contraception is questioned by many Catholic theologians, myself included. Moreover, very many Catholic couples do not seem to follow it in practice. However, the purpose of this article is not to discuss directly the teaching of Humanae Vitae on contraception, but merely to argue that condom use for HIV-protection is not excluded by this teaching.
Moral considerations arising from the wider context
Around the world there are various public health campaigns seeking to tackle health and welfare issues, including HIV. The quality, reach and accessibility of these is variable, but they make up an important social context which needs to be considered. For instance, there are HIV-prevention programmes which actually promote the usage of condoms whenever people at risk are having sex together. As has already been noted, this can happen in a variety of scenarios. The aim of such programmes is to prevent the spread of HIV-infection. They belong within the field of health promotion. Their objective is HIV-prevention, not birth-prevention. Hence, within such programmes condom use is specifically for a quasi-therapeutic purpose. Contraception is not the issue. Moreover, the intention of those promoting such programmes is presumably to promote ‘safe’ (i.e. non HIV-infectious) sex. It is not to encourage casual sex which would be socially irresponsible.
Nevertheless, such programmes raise some moral questions. But the questions they pose are not to do with contraception but with public health promotion. There are arguments for and against such programmes.
On the one hand, it is argued that making condoms easily available for young people facilitates immature and irresponsible relationships and so constitutes a threat to the young people themselves as well as to the social health and well-being of the society. The health and well-being of any society depends largely on the stability of families, whether in marriage or other similar long-term relationships. It also depends on the education of young people in social responsibility, including developing a capacity for mature and lasting life-giving relationships.
On the other hand, it is argued that where the environment is so unstable, many people, including those in the younger age group, feel pressurised into sexual activity with all the resultant risks of HIV-infection, and therefore that information and education is important to reduce those risks. The power of these social and environmental pressures is vividly described by Ann Smith (cf. supra, pp. 155-156).
A further social dimension also needs to be considered. If society is concerned to do all it can to ensure that parents are sufficiently mature and able to shoulder their child-rearing responsibilities, governments, local authorities and other concerned bodies will naturally be relieved when young people do not become parents before they are fit and able to undertake such a major role. The very instability of the environment makes it difficult or even morally impossible for many young people to enter into or maintain responsible long-term relationships and hinders the process of their maturing in social responsibility. The result of this can be a succession of partners, or multiple partners, all of which leave such young people much more vulnerable to HIV-infection. In the kind of socially unstable situation where HIV and AIDS are usually found, it could be argued that the availability of condoms to avoid HIV-infection might indirectly also prevent young people from becoming parents before they have matured sufficiently for such a role and before they have developed the kind of stable relationship needed for the healthy human upbringing of children. In that way, condoms could be playing an indirect, though important, role in furthering their personal and sexual development. The birth prevention involved here is not the purpose of the condom-use and so is not the deliberately intended contraception Paul VI is referring to. In their context and faced with the widespread threat and fear of HIV-infection, the prime concern and, in many cases, perhaps the only concern, of these young people would be to avoid HIV-infection. Likewise, the key motivation of health authorities in promoting condom-use would be HIV-prevention and health promotion.
Faced by such conflicting considerations the most helpful moral tool for resolving the dilemma would seem to be the ‘principle of double effect’ with its fourfold conditions. The first three conditions all seem to be fulfilled – 1. the act (condom-use) is not evil in itself; 2. the intention (health protection) is good; and 3. the evil effect (weakening of moral standards) is not a means to the good effect (HIV-prevention). Therefore, it would seem to come down to whether there is a proportionate reason for allowing the harm to occur. In other words, on balance does the good achieved outweigh the harm caused? The negative impact on social health through facilitating more casual sex and hindering personal development through its over-individualist focus needs to be weighed against the health-promotion effect in terms of preventing even more widespread HIV-infection.
This is an extremely difficult judgement to make. Society has the unenviable task of judging which policy is likely to bring about the greater good and cause least harm. Christians, Church authorities and NGOs have a responsibility to offer what wisdom and experience they can contribute to this difficult debate. In making their contribution it is important for them to recognise that they are dealing with a prudential judgement. To appeal misguidedly to the prohibition of condom-use as a moral absolute on this matter would be tantamount to short-circuiting the discussion. That would be inexcusable since what is at stake here is the possibility of a serious threat to the health and even life of many, especially women, currently at risk of HIV-infection.
The greater vulnerability of women
Statistical evidence shows that women are more vulnerable to HIV-infection than men. Often use of a condom by the male will be an essential safeguard for the health, even the life, of the woman. Yet mutual agreement on condom use is rare. Many men refuse to use a condom, regarding it as unmanly and diminishing their sexual enjoyment. Because of the inferior status of women in many cultures, it is not within their power to insist on condom use. Even women sex workers, driven by their family’s poverty to earn as much as they can, are often forced into unprotected sex for commercial reasons. As long as such widespread inequality continues, any blanket prohibition of condoms consolidates still further the oppression suffered by these women and is hardly in keeping with the liberating message of the Gospel. The heart of the ‘The Gospel of Life’ (cf. subtitle of this article) speaks a specific challenge to men in the kind of situations envisaged here – ‘if you are not going to respect these women sexually, at least respect their lives and do not threaten their health by unprotected sex’.
This highlights an obvious weakness in any approach which is too reliant on condoms. It still leaves men in control. What is needed is a major cultural shift so that men and women recognise each other as equal partners in any sexual exchange. Whether or not a condom (male or female) is used should be a matter of mutual agreement. Such a cultural shift would also involve liberating men from ‘macho’ stereotypes of masculinity and so empowering them to accept the mutual equality of both sexes.
Obviously, those opposed to condom use policies need to propose some alternative strategy for HIV-prevention. In fact, over many years a number of highly professional self-help educational programmes have been organised. Working on a peer-group principle, these are staffed by deeply motivated young people themselves. Inspirational pioneer work was done in this regard by Sister Miriam Duggan of the Congregation of Franciscan Missionary Sisters of Africa, a renowned surgeon and former Medical Director of St Francis Hospital, Nsambya in Kampala. When I visited Uganda in 1994 I was told that her ‘Youth Alive Clubs’ had attracted 5,400 young people as members. Their aim is to help young people appreciate the value of abstinence before and fidelity within marriage in terms of respect for themselves and their future partners, as well as its obvious role in HIV-prevention. Such initiatives are admirable and deserve support from Church and State, though a proper evidence-based analysis of the long-term effectiveness of such programmes is still needed to give them greater credibility.
Conclusion
Whatever line one takes on the condom issue, no HIV-prevention programme can afford to turn a blind eye to the enormous pressures coming from the wider environment and with the consequent effect of virtually disempowering many vulnerable individuals and leaving them with a very limited ability to make any kind of ‘free’ choice. It is impossible to stem the deadly spread of the AIDS pandemic unless the root causes which make people vulnerable in this way are unearthed and tackled. Any specific HIV-prevention programme will only be really effective if it is part of a fully comprehensive strategy. Over and above methods aimed at direct risk reduction, such as using condoms as a barrier to HIV-infection, eradicating root causes such as poverty, gender inequality, sexual violence, stigma and enforced migration are essential elements of any comprehensive HIV-prevention strategy.
On my first AIDS-related visit to Africa I had the privilege of meeting Noerine Kaleeba, a Ugandan woman whose husband had died of AIDS in the early days of the pandemic. Together with some companions who were going through a similar experience, Noerine and her husband, Christopher (while he was still alive), had formed TASO (The AIDS Support Organisation). By the time I met Noerine in 1994 TASO had grown into one of the largest and most effective HIV and AIDS support organisations in sub-Saharan Africa. The TASO group, like Noerine herself, made a deep impression on me. Their attitude was extremely positive. Their slogan was ‘Living positively with AIDS’. For them AIDS made people much more aware that each day of one’s life was a precious gift to be lived as fully as possible. While completely professional in catering for the multiple needs of people living with HIV/AIDS, they encouraged them to live positively. At a meeting of Asian theologians on HIV and AIDS I attended in Bangkok some years ago, something similar was said by a Thai man who spoke to us. After his life had fallen apart for a time, he seemed to find a new sense of direction when he discovered he was HIV-positive. The words he used to describe his experience were, ‘AIDS is my gift’. While none of us could accept that life-threatening AIDS is a gift, his words brought home to us how profoundly it had affected his life.
Any Christian approach must be positive in its outlook and life-promoting in its aims. Jesus says: ‘I have come that they may life and life in its fullness’ (John 10:10). Certainly, the deepest desire of the MMM sisters mentioned earlier and the desire of all involved with HIV and AIDS is that those who live with, or who are affected by HIV ‘should have life, and life in its fullness’. The emphasis must be, and must be seen to be, a ‘yes’ to life, rather than just a ‘no’ to condoms. Perhaps what is most prophetic in Paul VI’s encyclical, Humanae Vitae, is its very title, ‘human life’. What is life-preserving and life-enhancing must be the guiding principle of any truly human, and Christian, comprehensive HIV and AIDS programme and must be brought to bear not just on individual relationships but also on the whole variety of social, cultural, political and economic forces which have an impact on the HIV and AIDS scene. It is a ‘yes’ to authentic human development in the fullest sense. It is interesting that the English title of Benedict XVI’s highly praised encyclical on the current economic situation is ‘Integral Human Development in Charity and Truth’.