HIV/AIDS AND LIFE

HIV/AIDS is about many things.  Clearly it is about suffering and healing, dying and death.  But it is also about sex and living and originating new life.  For very many, especially women, it is about coping and managing on an inadequate or non-existent income.  For others, it is about caring for children who have no one to look after them, while at the same time it is about caring for old people whose adult children are no more.

Together, the disease and the epidemic that has resulted from it cover almost every aspect of human life.  As they do so, they give rise to a whole host of ethical and theological questions.  In many cases, HIV/AIDS highlights and magnifies the ethical implications of existing situations, such as widespread poverty or the unjust treatment and exploitation of women.  In other cases, HIV/AIDS raises new issues with ethical dimensions, such as in the areas of stigma and discrimination or access to antiretroviral drugs (ARVs).  In many circumstances, responding to these issues implies two judgements that tend to strengthen each other:

·         This should not be, it is unethical.

·         This must be changed, it makes the HIV/AIDS situation worse.

Areas of ethical and theological challenge presented by HIV/AIDS would include:

1.       Protecting truth, and excluding denial and stigma

2.       Remedying the status of women and correcting gender imbalances

3.       Doing something about the sinful conditions of the unjust distribution of wealth, widespread poverty, and oppressive globalisation

4.       Ensuring the protection of human rights that are threatened by HIV/AIDS

5.       Understanding sexuality and dealing with its practice

6.       Reconciling the demands of confidentiality with those of the public good

7.       Ensuring the comprehensive practice of personal and communal responsibility both to and by those who are HIV infected

8.       Balancing the competing demands of AIDS treatment and HIV prevention when it comes to the allocation of resources.

A few of these issues are dealt with below (if readers want more, a further article can deal with the remainder).

STATUS OF WOMEN AND GENDER IMBALANCES

HIV/AIDS has a disproportionate effect on the lives of women.  On physiological and health grounds they are at greater risk of becoming infected with the virus.  On social and economic grounds they are more vulnerable to infection.  And when HIV/AIDS is present in a household, women are likely to carry the larger share of the burden and to be more extensively affected.

There can be little doubt that HIV/AIDS is increasingly becoming a disease with the face of a woman or girl.  In the words of Stephen Lewis, the UN Secretary-General’s Special Envoy for HIV/AIDS in Africa, “the pandemic is now, conclusively and irreversibly, a ferocious assault on women and girls world-wide”.

Theologically this is not as it should be.  Scripture tells us that “male and female God made them.  In his own image and likeness  God made them.”  There is no question here of one being subordinate to the other, of one carrying a heavier burden than the other.  There is no theological reason for the concentration of AIDS among women.

Neither is the “feminization of AIDS” ethically right.  The Universal Declaration on Human Rights affirms that “all human beings are born free and equal in dignity and rights”.  But until such time as women’s full dignity as human persons and their full equality with men is proclaimed and practised in every walk and stage of life, this article will remain a pipedream.  Humanity will remain out of harmony with its best aspirations.  It will not be true to itself.

Meanwhile, women and girls will remain at the epicentre of the HIV/AIDS epidemic.  The relationship of respect, mutuality and equality between women and men will continue to be violated.  In practice, the inherent human dignity of women will be denied.  An unethical approach will be maintained and HIV/AIDS will continue to flourish.

POVERTY

HIV/AIDS has never been a democratic disease.  Although in its early days it occurred more among the better-off, it settled down fairly quickly to targeting the poor and vulnerable.  The poor are at higher risk of HIV infection; the poor are more vulnerable to HIV infection; and the disease makes the poor poorer.  In circumstances of personal poverty and underdevelopment, HIV transmission occurs more easily while the period of HIV infection prior to the emergence of clinical AIDS tends to be shorter.

Circumstances over which they have virtually no control put the poor at higher risk of HIV infection.  Such circumstances include a greater likelihood of untreated STIs; absence of information on their own HIV status or that of their sexual partner; the increased possibility of high-risk behaviour because of difficulties in accessing and storing condoms correctly as well as major constraints in using them properly; and economic pressures to resort to the sale of sex to generate household income.

In addition, many factors that are almost entirely outside their control make the poor more vulnerable to infection.  Long prior to HIV infection, their immune system may be weakened because of their low health and nutritional status, their limited access to health care, their inability to meet the costs involved in accessing health services, and their increased exposure to other health hazards, such as malaria, TB, or gastro-intestinal problems.

The poor constitute the majority of those who migrate from place to place in seek of labour and better living conditions. But only too often they replace joblessness, overcrowding, poor housing, inadequate sanitation, and poor health and educational facilities with similar situations elsewhere.  In this way, they carry the burden of their HIV vulnerability with them.

Clearly this is not the way things should be for forty percent and more of humanity.  God did not make the world so that things should be like this.

Equally clearly, the continuation of such a situation will not serve to roll back HIV/AIDS.  The concentration of wealth in the top 5–10 percent of a society; half-hearted poverty reduction programmes; the application of globalisation measures in ways that are to the disadvantage of poorer countries; the continued siphoning off of financial resources to debt repayments; the brain drain that eats away the human capacity of poor countries; maximising profits at all costs; corruption and cronyism at all levels; the mismanagement, poor governance, and poor and unconcerned leadership that is crippling the potential of many poor countries; the concentration of efforts and resources on the retention of political power; internal and international conflicts and wars -- all play their part in maintaining the poverty of peoples and thereby all play their part in maintaining or worsening the HIV/AIDS situation.

Each one of these situations is unethical, it is not as it should be.  Each serves to maintain the unethical situation of mass poverty in a world plentifully supplied with means and resources.  Each contributes unethically to the prolongation of the wretchedness of HIV/AIDS.

THE UNDERSTANDING OF SEXUALITY

Sexual contact is the commonest means of HIV transmission, accounting globally for about 90 percent of cases.  Because of this, the understanding of sexuality and the ethics of sexual practice and customs play a critical role in approaches to HIV prevention.

Sexuality is a drive for intimacy, union, relationships, wholeness.  It expresses the need a human person feels to find completeness and real fulfilment by handing the self over in some enduring commitment to another person.  Sexuality is never casual, neutral, unimportant, or just recreational.  It goes beyond genitality and body-to-body contacts. Instead, it stresses person-to-person interchange.  What sexuality prizes most highly is interaction with the other as a person.

In many cases, the personal as well as the physical contacts of true sexuality are freely agreed upon.  But much sexual contact is also forced -- physically and/or psychologically -- especially on the young and on women and girls.  In addition, many societies debase the true meaning of sexuality through the different standards and expectations they have for men and boys on the one hand and for women and girls on the other.

The “machismo” image found in many societies is a caricature of true sexuality, reducing it to physical sex activity and male dominance, prowess and control.  Likewise, what can be called the “feminismo” image is also a caricature in the way it portrays sexuality in a girl or woman as docile, submissive, yielding, and accepting of whatever comes from the male, whether sexual advances, decisions, economic power, or gifts.  Neither approach can give expression to the love, care, intimacy, and joy that characterise true sexuality.

This immediately raises questions about the way sexuality is portrayed in the media and anti-HIV messages.  Too often these seem to reduce sexuality almost to a commodity that can be traded (usually by women and girls).  To the extent that they do so, they foster wrong thinking and ensure failure to promote appropriate life-affirming behaviour.

HIV/AIDS raises other difficult ethical and pastoral questions in the area of sexuality:

·         Can we continue to acquiesce in double sexual standards for men and women, especially as manifested in “machismo” and “feminismo”?  What can we do to change these double standards?

·         As church people, are we giving a lead in speaking against these double standards and in promoting positive attitudes to sexuality?

·         What are we doing in our school programmes to ensure that young people develop a proper understanding of human sexuality and the right attitudes to it?

·         Can we continue to tolerate attitudes and practices  that relegate homosexuals and lesbians to the margins of society?  Is it right that homosexuality should be a criminal offence?

·         Can we continue, in our communities and churches, to overlook the fact that so many children suffer sexual violence, in silence and in their families.

Our thinking in these areas should be guided by three questions.  Is this right?  Does it make the HIV/AIDS situation better or worse?  What would have been the Lord’s reaction to the practice or situation?  Our answers may well show that, like Abraham, we are being challenged to journey into new and unexplored territories of belief and practice.

REDUCING THE RISK OF HIV TRANSMISSION

The ideal situation would be to see an end to every form of sexual behaviour that puts an individual at risk of becoming infected with HIV.  In practice, however, it must be acknowledged that such forms of behaviour seem certain to continue.  In spite of the risk of HIV transmission, our Christian communities, like the rest of the world, will almost certainly continue to see instances of early sex, pre-marital sex, casual sex, drug or alcohol induced sex, commercial sex, sex with multiple partners, extra-marital sex, bisexual activities, and homosexual activities.

Many of these increase the risk of HIV infection.  There is also the tragedy of many married women becoming HIV-infected through their fidelity to husbands who themselves are not faithful.

Such situations make it necessary to consider what can be done in circumstances like these to reduce the likelihood of HIV transmission.

Where there is the possibility that sexual activity might involve the risk of becoming infected with HIV or transmitting the disease, the experts propose four harm-reducing practices:

·         Reduction in the number of sexual partners.  Ideally this would find expression in fidelity to one partner in a stable union.

·         Delay or postponement of sexual activity.  Ideally this would find expression in abstinence and the avoidance of sexual intercourse outside of a stable married union.

·         Sexual activity without penetrative intercourse.

·         The consistent and proper use of a condom.

ABSTINENCE AND FIDELITY AS PRIORITY

Together with those from other faiths and religions, the Catholic Church has been outstanding for the consistent and forceful way it has promoted the first two options, abstinence before marriage and mutual fidelity within marriage.  Abstaining from penetrative sex and remaining mutually faithful in a relationship where both parties are HIV-negative are the only sure ways of preventing HIV transmission.  The insistence of the Church on these principles has kept them prominent in people’s thinking.  The Church’s insight here also corresponds to what the majority of people see as being best in human behaviour.

Clearly abstinence and fidelity are the most desirable course of action.  They are also the course of action adopted by most people. This is shown by the fact that even in the countries most severely affected by HIV, three-quarters and more of the people are not infected, implying the likelihood that a very large percentage do in fact abstain from risky sexual activity and/or live in mutual fidelity in the safe union of a marriage where neither partner is infected with HIV.

Apart from the way they match up to the highest ideals in human sexual practice, abstinence and fidelity have a further merit.  They represent really substantive behaviour changes (or the maintenance of intrinsically valuable human behaviours).  Hence they are more likely to be sustained than the more superficial behaviour change involved in condom use.  Like good driving, abstinence and fidelity come from internal values that have developed good practices.  Like using a safety belt, condom use is an externally applied protection for emergency situations.

CONDOM USE

But while abstinence and fidelity remain the ideal (and the practice of very many), a place has to be found for the other two options (non-penetrative sex and condom use).  Hence it is necessary to ask whether they can be upheld on moral grounds.  The answer is that they can, with the ethical justification for these practices, and for advocating them, lying in the principle of the lesser evil (and for married couples, in the principle of double effect).

The principle of the lesser evil states that if an individual contemplates placing an action that involves the violation of more than one ethical principle, it is lawful (and in certain circumstances even obligatory) to modify the action in a way that will reduce the violations.  For example, if an individual is determined to carry out a robbery with violence, it is legitimate to counsel that, whatever else may happen, violence should be avoided.

In the case of high-risk sexual activity, there may be two evils -- the wrong use of sex and the danger     of       transmitting (or acquiring) a potentially life-threatening infection.  The first evil violates chastity.  The second violates justice by posing a threat to the health or life of an individual.  The principle of the lesser evil states that if sexual activity is to take place in these circumstances it should be performed in such a way that the danger of transmitting HIV is eliminated or at any rate reduced.  Since the condom reduces this risk, its use can be advocated.

The ethically wrong use of sex remains, but without a condom the action would add the further ethically wrong dimension of putting oneself or another person at risk of HIV infection.  In the recent words of a consultor to the Vatican Congregation for the Doctrine of the Faith, in contexts such as this, “the problem is not condoms.  The problem is disordered sexuality”.

Even more direct and forthright were the comments of Belgian Cardinal Godfried Danneels in a television interview on 11^th January 2004: “When someone is HIV-positive and his partner says 'I want to have [sexual] relations with you,' then he does not have to do it.  But if he does, he has to use a condom.  Otherwise he will commit a sin.”  In the view of this senior Cardinal, condom use is not only morally lawful but, where HIV is present, is morally required.

But to say that condom use can be morally justified in certain circumstances does not mean that it is right to distribute condoms indiscriminately.  And it is very far from saying that it is all right to have sex provide you use a condom.  Handing out condoms to every passer-by as though they were sweets is irresponsible and unethical.  Efforts should be made to ensure that those who are to have access to this safety device have had an opportunity to develop some understanding that abstinence and fidelity are usually the better moral choice.  They should also be helped to know that while the condom offers a large measure of protection against HIV infection, it is not necessarily one hundred percent effective.

In this whole discussion, then, ethical concern for the truth requires that all parties accept the truth of a number of statements, namely that:

·         abstinence and fidelity are the only totally effective ways of avoiding HIV infection;

·         abstinence and fidelity are the most desirable (and usually the most culturally acceptable) ways of avoiding HIV transmission;

·         condom use can be morally justified;

·         there may be circumstances where condom use is morally required; and

·         for a variety of reasons condom use may fail to prevent HIV transmission.

CONCLUSION

When convening the Second Vatican Council, Pope John XXII called for the windows of the Church to be opened, so that the light of the Holy Spirit might have a better chance to shine in dark corners.  At this time of HIV/AIDS, each one of us needs to open the windows of our hearts to let the light of God’s Spirit of truth shine within us.  We all need the light of the Holy Spirit to know what is right in our present circumstances.

Likewise, we need the strength of the Spirit, the Comforter, the One-Who-Strengthens, to say and do what we see to be right with regard to promoting the full equality and dignity of women, making a meaningful onslaught on poverty, and fostering a more joyful acceptance of God’s great gift of sexuality.  In these ways we will serve people better, we will promote life-saving responses to the HIV/AIDS epidemic, and we will embody better in ourselves the bountiful God whom Scripture represents as Father, Mother and Spouse.

Michael J. Kelly, S.J
Luwisha House
Lusaka