The Tablet, September 24, 2004
Catholic Aid Agency in UK Supports
Should condoms ever be part of faith-based HIV
prevention? The Catholic aid agency believes
they can be but only as part of a much
Ever since the HIV virus was first identified,
the issue of how best to halt its spread has
deeply divided those working in the area. The
Tablet has published in recent months a number
of articles by theologians, statements from
bishops and cardinals, and reports of debates
among those working to combat Aids in developing
countries. The discussions between faith-based
and secular organisations at the recent international
Aids conference in Bangkok show that the issue
of condoms in the fight against HIV has not
cooled, and remains a major source of controversy,
often pitting religious and secular
against each other. Cafod, the Catholic development
agency of England and Wales, believes it is
time to make clear its approach to HIV prevention.
Sadly, all too often the debate has involved
a contest between condom only or
abstinence/fidelity only solutions.
These have often been hijacked by political,
religious or cultural agendas in turn fuelled
by mutual distrust and prejudices. A third,
middle-ground approach known as ABC
abstain, be faithful, use a condom
has also emerged.
But all three approaches often assume simplistic
solutions for an idealised world in which all
individuals are free to make empowered choices.
This is not the reality for most people worldwide
affected by HIV. Cafods approach seeks
to take into account the complex social, cultural
and economic factors that influence behaviours
and condition choices, most particularly (but
not only) in countries of the South where the
impact of Aids has been disproportionately
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-positive women
worldwide are infected by the person they considered
to be their monogamous, life-long partner.
Because too often they fail to take in the wider
picture, simplistic prevention strategies are
doomed to failure, even in the short term.
A fuller understanding of HIV prevention is
called for, one that identifies three layers
in the pandemic: impact, risk and vulnerability.
HIV prevention strategies must address all
three layers if they are to be effective.
The first, impact, emphasises the essential link
between care and prevention. Keeping those
affected by HIV in good physical, emotional
and economic health for as long as possible
is an essential component of prevention, as
it helps avert the decline of families into
poverty and the stigmatisation that fan the
The second, risk reduction, involves providing
individuals and communities with an accurate
and full understanding of the risks of infection.
It means helping people to acquire the skills
and resources to make changes in their personal
or professional lives to minimise these risks.
This means enabling people to adopt measures,
based on the fullest scientific evidence available,
that afford them immediate protection, partial
or complete. Typical risk reduction strategies
include abstinence, mutual fidelity, reducing
the number of sexual partners and condom use.
Because the sexual route is not the only source
of infection, it means also ensuring safer
blood transfusions, drug injecting and antenatal
and delivery practices.
But reducing the risk of infection is not about
choosing one or other option randomly, or to
suit social or religious pressures. It is preferable
to think of it in terms of a continuum running
from high-risk activities to those carrying
low or even no risk. Reducing risk is a process,
an education, in which people come to see what
risks their behaviour entails and in which
they take steps to reduce that level of risk
in their circumstances. Any strategy that enables
a person to move from a higher-risk activity
towards the lower end of the continuum, Cafod
believes, is a valid risk reduction strategy.
This strategy is based on sound theological principles.
Traditional moral theology allows for an approach
in which individuals subscribe to clearly identified
ideals but sometimes have to make choices that
fall short of these.
The third layer vulnerability requires
HIV prevention strategies to address the fact
that, too often, peoples behaviour cannot
change until their wider circumstances change.
Discriminatory or unjust economic, social, cultural,
legal, political, gender-related and, on occasions,
religious, factors, significantly curtail the
behaviour choices of those who are vulnerable
to infection. Initiatives which aim to reduce
vulnerability are, and must be, recognised
as essential components of a fuller HIV prevention
strategy. The Church, with its rich body of
doctrine and theology of Catholic social teaching,
demands that those working in Church-based
initiatives denounce these injustices and work
to redress imbalances.
Cafod believes that any attempt by an individual
to carry out their chosen risk reduction strategy
constitutes behaviour change for that person.
It believes that Church-based programmes must
help people to grow more fully in their God-given
identity. No less demanding is the prophetic
role of these programmes in seeking the social
transformation that will enable personal growth.
Cafod also believes in an ABC approach,
but not in the simplistic terms in which it
is often promoted. We see ABC as belonging
to one layer risk reduction of
the three needed for effective prevention.
Promoting abstinence, for example, means upholding
the value of not having sex until marriage
while also recognising that for some young
women abstinence might mean delaying the age
of first sexual encounter beyond the more physiologically
vulnerable teenage years. For other women and
men, it might mean waiting until they are in
a more stable relationship. Similarly, the
exhortation to be faithful means
exhorting married couples to be mutually faithful
for life, as the Church teaches. But we also
acknowledge that, in other contexts, this component
can also mean fidelity to a single long-term
partner or fidelity to a strategy of reducing
the instances of casual sex.
The data is clear that condoms, when used correctly
and consistently, reduce but do not remove
the risk of HIV infection. This fact cannot
be excluded from or misrepresented in any information
on risk reduction strategies, regardless of
the political or moral position of those promoting
them. Condom campaigns have been particularly
effective with groups at the highest risk
prostitutes, for example who may have
few if any other realistic options for reducing
this risk. But these campaigns have been considerably
less effective in general population public
health strategies. Cafods approach condemns
the condoms only or even condoms
mainly campaigns for the general population,
which have often been promoted with the same
dogmatism as some abstinence only
campaigns, and which similarly distort information.
Ugandas success in significantly reducing
the incidence of new HIV infections is often
cited in support of the A and B approaches.
But there were many and diverse factors at
play in Ugandas Aids campaign that have
contributed to its success in reducing infection
rates. President Yoweri Museveni and his Government
threw themselves behind the campaign at an
early stage; public figures including
church leaders were honest about the
reality of Aids and committed to tackling it.
Uganda has changed certain cultural practices
and introduced laws to outlaw gender violence
and sexual coercion. It also moved from a state
of war to one of relative peace, reaping the
benefits in greater economic stability and
employment opportunities, as well as increased
access for women to education, employment and
political life. Within this scenario, one component
was an ABC component which, while emphasising
A and B, did not exclude condoms.Ugandas
HIV prevention policy in fact shows just how
valid is Cafods three-layer
approach. Uganda mitigated the impact, reduced
risks and decreased vulnerabilities.
The three-layered approach taken by Cafod calls
for diverse groups from every sector of society
to contribute to a shared strategy for HIV
prevention. It calls for complementarity and
collaboration and for the dismantling of mutual
prejudices. It deplores the obstructive positioning,
judgementalism and dogmatism of opposing factions
that too often feature in simplistic polarised
approaches. It reconciles solid science and
good community development practices with established
and evolving moral theology and Catholic social
The Catholic Church is deeply rooted in local
communities throughout the developing world
and is a major contributor to the struggle
against Aids in countries worst affected by
the pandemic. Cafod believes that the Church
is therefore well placed to promote this more
holistic understanding of prevention and to
foster reconciliation between opposing factions,
drawing these towards an attitude of mutual
acceptance and collaboration.
The challenges of the pandemic are urgent and
compelling, the challenges of the Gospel no
less so. Future generations will hold us to
account on both. The understanding of HIV prevention
presented here has been developed from Cafods
experience of almost 20 years of supporting
partners community-based HIV programmes
in developing countries, and from its ongoing
theological reflection on the complex issues
raised by HIV. It is the only understanding
of HIV prevention that Cafod can, with integrity,
seek to promote. It does so as and is
proud to be a development agency of
the Catholic Church.
Ann Smith is HIV corporate strategist at Cafod.
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