THE RELIGIOUS CONSULTATION
on population, reproductive health & ethics

The Tablet, September 24, 2004

Catholic Aid Agency in UK Supports Condom Use

Ann Smith

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 broader approach.

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. Cafod’s 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 catastrophic.

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 pandemic.

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, people’s 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. Cafod’s 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.

Uganda’s 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 Uganda’s 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.Uganda’s HIV prevention policy in fact shows just how valid is Cafod’s “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 teaching.

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 Cafod’s 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.