Living Positively in a a Time of AIDS

Living Positively with AIDS: A Lesson from Uganda

From New Directions in Sexual Ethics by Kevin T. Kelly, Geoffrey Chapman, 1998, Ch. 8

The subtitle of this book is Moral Theology and the Challenge of AIDS. Having listened to the challenge of the AIDS pandemic in Chapter One, we have been exploring how Christian sexual ethics should respond. These closing two chapters bring us back to where we began, the AIDS pandemic and its impact on developing countries. This chapter will look at some of the practical implications of 'living positively with AIDS' and will examine some good and some questionable Church practice. The final chapter situates the AIDS pandemic in a global frame and suggests that responding to the challenge of 'living positively with AIDS' could actually be a time of grace for our world.

I first heard the expression 'living positively with AIDS' from the lips of Noerine Kaleeba, a Ugandan woman whom I was privileged to meet in Kampala. She is an extraordinary person. Her personal story is a living example of the meaning of 'living positively with AIDS'.

Noerine was more fortunate than many Ugandan women in that she had a good education. This led to her becoming a physiotherapist in the major hospital in Kampala. Her husband, Chris., worked in Adult Education and eventually got a scholarship to do a PhD at Hull University. He came to England in 1985. This was right in the middle of Uganda's second civil war in 10 years. During the winter of 1985 Noerine and her four daughters spent 3 days hidden in a cellar without food and water, hiding from Obote's fleeing soldiers who were killing and raping as they left. On 6 June 1986 Noerine got news that Chris was seriously ill in hospital in Hull. She was told he had AIDS.

At that time, she knew little about AIDS, connecting it with white homosexual men in San Francisco, though there had been rumours of a similar condition in the Ugandan border region of Rakai. Naturally, Noerine told her family, friends, neighbours and work colleagues about Chris's illness. She thought nothing of letting them know he had AIDS,

She flew to England and found Chris was desperately ill. The doctors counselled Noerine to have an HIV test herself. This proved negative but they warned her that this did not guarantee she was not infected with HIV She would need to have another test at a later stage. For the sake of her daughters, Noerine had to leave Chris in September and return home. When she got back to Uganda, she found that nearly everyone began to shun her and her daughters. Due to ignorance, they thought that AIDS was infectious in a similar way to measles. This was a very difficult and isolating time for Noerine., especially with the additional strain of her being separated from Chris in his illness. When Chris's health showed some signs of improvement, he was able to return to Uganda in October. However, he soon had to go into hospital in Kampala. There, to Noerine's horror, the nurses would not even enter his room and she herself had to do all the nursing, even quite technical medical procedures. As well as shunning her, people were just waiting for Noerine herself to show signs of AIDS and start dying. The only support that Noerine and Chris got at this time was from a little group of people whose lives had also been affected by AIDS. In fact, twelve of them actually had AIDS themselves.

Eventually Chris died from AIDS-related meningitis. Noerine was totally devastated by his death, by the terrible pain in which he died and by the way she and her daughters had been treated. To make matters worse, although Chris had made a will, it was not sufficiently specific to override local custom. Consequently, in accordance with the patriarchal traditions of their culture, the house in which Noerine and her daughters were living and the bit of land that went with it did not go to her and her children but to her husband's brother. Ironically, it was only much later that Noerine discovered that Chris had probably been infected with HIV due to a blood transfusion (8 units) he had received from his brother after he had been knocked down by a bus in 1983. That brother died of AIDS the year after Chris.

Noerine believes that one of the gifts God has given her is a positive approach to life. If something is wrong and can be changed, she must do whatever she can to make things better. What she experienced in the course of Chris's illness and death convinced her that there was a great deal wrong in Uganda with regard to the AIDS scene:

the medical care for people with AIDS was appalling;
ignorance about AIDS was causing people living with AIDS, along with their children, to be shunned by everyone;
the cultural subordination of women was creating a whole host of problems and these were either contributing to the spread of AIDS or were making it even more difficult for women whose husbands were infected
parents with AIDS were fearful about what could happen to their children when they died.

Noerine got together the sixteen people who had formed the little support group which had been so helpful to Chris and herself. They decided to try to do something practical to improve things at all these different levels. From this small beginning TASO (The AIDS Support Organization) was born. By 1994 when I visited Uganda, it was having a major impact on the AIDS scene in Kampala and many other parts of the country and was being seen as a model for other countries to follow.

Initially TASO concentrated on information-giving and counselling. The only messages people were receiving were 'AIDS kills' and 'Love faithfully and beat AIDS'. Neither of these slogans offered any hope to people who were already HIV positive. Noerine believed that they needed something more to empower them to live their lives positively. Counselling and good medical care were both needed. But factors which affected the whole family also had to be faced. So there was a need for a more holistically directed approach, including tackling the issue of behaviour change. TASO gradually developed a whole system of health workers, local clinics and trained specialist nurses to work with people with AIDS. To combat ignorance about HIV/AIDS they trained local community workers and established a comprehensive network of them in different parts of Uganda. They also established a body of trained counsellors. These were in great demand since it is not easy for a young person to discover that he or she will die soon, and even harder if they have a young family. To tackle the problem of women left without home or land they developed a whole series of income-generating projects for widows and orphans to help them be self-supporting. They also formed women's support groups to try to change the abuse of women in their culture. Linked to this they began working with a group of women lawyers who were trying to make the law more respectful of women and who were promoting the making of wills which would safeguard the rights of women when their husbands died. And finally, they got funding to pay the school fees for AIDS orphans to enable them to have a better chance in life.

When I visited TASO in 1994 they were supporting 370 orphans over an 8-year schooling programme. Sadly, they had a further 15,000 orphans on their books whom they had assessed as needing help. By 1994 TASO had 250 paid staff and its budget, mainly from overseas relief agencies, was $1.5 million per year. It had also trained 1.800 community volunteers as AIDS counsellors in the villages. Their paid workers operated in 7 centres across Uganda, all at important points along the TransAfrican Highway, and their outreach programmes covered a 40 km radius around each centre. At that time they had decided that they could not expand any further and so their priority was changing to a broadening of their educational capacity so that they could help other new groups which are springing up. Tragically, the majority of the original sixteen founding members of TASO have already died of AIDS.

Noerine has written up her personal experience in a very moving little book entitled We Miss You All (Harare, Zimbabwe, Women & AIDS Support Network, 1991). Her inspiring but very down-to-earth understanding of what it means to 'live positively with AIDS' comes out clearly in the following passage:

Living positively with AIDS. The public health messages were saying 'Beware of AIDS. AIDS kills', 'You catch it and you are as good as dead'. There were no messages for those people who were already infected. What was implied was that people who were already infected should die and get it over. People with HIV and AIDS were seen as dying. We adopted the slogan of 'Living positively with AIDS' in direct defiance of that perception. We emphasised living rather than dying with AIDS. For us it was the quality rather than quantity of life which was important. Once infected with a deadly virus like HIV people need to take definite steps to enhance the quality of whatever life they have left. They must develop a positive attitude to life . . .

The TASO slogan is 'Living positively with AIDS' and calls on everyone in society, infected or non-infected. To the person who is infected it calls on them to live responsibly with the HIV infection in their blood, to face up to the infection as a starting point. It calls on them to recognise their responsibility to society, the responsibility to retain the amount of virus they have in their blood, and not spread it around, by making the effort not to infect others. It also calls upon people who are infected to look after themselves better, and preserve themselves until a cure conies. It calls to people who are infected to remain actively involved in society, and in social activities within society. It also calls upon the rest of society to support people with HIV infection so that they can fulfil their obligations . . . Acceptance of people with HIV or AIDS within our community is a very important starting point for dealing with the problem, (pp. 79-80).

Noerine also mentions why she refused to have a second HIV test. She was afraid that if it showed her to be HIV negative, she would be less in solidarity with other people who were living with AIDS. That is part of how she understands 'living positively with AIDS' in her own personal life.

This lengthy account of how Noerine has been living positively with AIDS and how she has inspired so many others to follow her example might seem a strange way to conclude a book on new directions in sexual ethics! Yet I believe it is most appropriate. The whole thrust of this book has been that it is not just individual men and women infected with HIV who have to live positively with AIDS. We all have to. And I have been arguing that part of living positively with AIDS for the Christian Churches involves a renewal and enrichment of our sexual ethics in response to the challenge of HIV/AIDS.

IS THE CHURCH LIVING POSITIVELY WITH AIDS?

YES, BUT . . .

Because of my limited knowledge of the situation in other Churches with regard to HIV/AIDS, my answer will refer mainly, though not exclusively, to the Roman Catholic Church. Following the 'Yes, but...' or 'No, but . . . style of answer adopted in the previous chapter, I would suggest that the answer in this case should be 'Yes, but . . . ', even though the 'but. . . ' is a large one!

I say 'Yes, but. . . ' rather than 'No, but. . . ' because my experience on the CAFOD AIDS committee has opened my eyes to the way so many Christians, right across the world, have responded extremely positively to the HIV/AIDS tragedy. In many of the developing countries, it is the Christian Churches who have led the way with immense heroism and generosity in HIV/AIDS work in all its different facets, hospital-based medical care, home care, educational work, counselling, caring for orphans, specialized work with young people, creating viable alternatives for women forced into prostitution, and so forth. The way CAFOD, for instance, has responded so creatively to the AIDS pandemic is indicative of a similar response among many other development agencies. A very moving and informative account of some magnificent AIDS projects linked together through the World Council of Church's process, Women and Health and the Challenge of HIV/AIDS, is found in Gillian Paterson, Love in a Time of AIDS: Women, Health and the Challenge of HIV (Geneva, WCC Publications and New York, Orbis, 1996).

I know from personal experience that much of the funding channelled through the CAFOD AIDS department has gone to projects which seem to be doing effective work in the following areas:

education for AIDS prevention by raising awareness and encouraging behaviour change;
preventative health care (testing the blood supply, clean needles, etc.);
caring for the medical, physical and social needs of those living with AIDS;
helping children who have become orphans through AIDS.

Because of their awareness of the ‘feminization of poverty’ dimension, CAFOD are always careful to examine whether projects take this into account. They know from experience that some local projects could actually be prejudicial to the interests and well-being of women. Moreover, CAFOD's involvement has always been based on listening to and supporting local people in the field. It has also been self-critical, always ready to learn from mistakes.

What about my large 'but. . . ' attached to my answering, 'Yes, the Church is living positively with AIDS? What does that large 'but. . . ' refer to?

It refers to the many instances where, sadly, the Churches seem to be part of the problem rather than part of the solution. That this is beginning to be recognized comes out in the interesting phenomenon that some of the CAFOD AIDS staff are increasingly being asked to help priests, religious and seminarians with issues related to sexual development and attitudes in their own lives, Tragically; many priests and male religious still believe in the inferior status of women as much as anyone else and this shows itself in the way they treat women, even women religious. Moreover, sadly, many women religious in developing countries have internalized a belief in their own second-class status. Consequently, this aspect of CAFOD's work is a case of training the trainers since all these people should really be playing an important role in facilitating behaviour change. If the Church is to play its potentially powerful role in combating the underlying causes of the spread of HIV/AIDS in developing countries, it has first to change itself and its ministers (men and women) from being an integral part of the problem. I could offer many other reasons for my suggesting that the 'but. . .' is a very large one. Many of these would be linked to the kind of issues dealt with in the third and fourth chapters of this book, namely, the sexual and economic subordination of women and the current teaching on gay and lesbian relationships.

However, rather than go over issues already covered earlier in the book, I would rather examine the question, 'Is the Church living positively with AIDS?', with particular reference to two specific issues not yet explored here and which crop up frequently in practice as well as in ethical discussions about HIV/AIDS. Consequently, I would like to explore the two questions: (1) Is a diocese or religious congregation living positively with AIDS if it demands the compulsory testing of candidates for the priesthood or the religious life? and (2) Is the Church living positively with AIDS when it opposes condom use as a help towards preventing HIV infection? My answer will be 'No' to each question.

1. Is a diocese or religious congregation living positively with AIDS if it demands the compulsory HIV testing of candidates for the priesthood or the religious life?

The question of compulsory testing is usually posed as an ethical dilemma focused on the values of personal freedom and the right to privacy. Like couples entering marriage, candidates for the priesthood and the religious life are also intending to exercise their freedom at its highest level in making a life-long commitment. Is compulsory HIV testing a violation of their freedom and their privacy?

There has been a considerable amount of writing on this point, putting forward all the points for and against such a policy. In favour of testing it is argued that such a requirement is not a violation of the candidate's freedom. After all, the candidate is making a life commitment to a particular diocese or religious congregation. Surely, it is claimed, a diocese or congregation has every right to lay down conditions for entry which they believe to have an important bearing on their ministry and mission. In a parallel instance, would it be a violation of her fiance's freedom if a young woman insisted that he should have an HIV test before she agreed to marry him? In the case of a diocese or religious congregation, it is argued that it is legitimate for them to check out whether the health prospects of candidates are such that there is a reasonable hope that they will be able to spend an adequate number of years in active ministry or at least without being a financial burden on the limited financial resources of the diocese or congregation because of deteriorating health. These finances have, after all, been donated principally for the support of ministry and mission. Moreover, canon law would seem to allow for such a requirement.

What about the arguments against testing? Some argue that HIV testing does not provide the kind of assurance that a diocese or religious congregation is looking for in terms of future health prospects. While that might be true, it would seem to be equally true that testing provides the only level of assurance that is available, however inadequate it may be. However, there are other problems involved in testing. The HIV test can give a wrong result. Also testing can result in excluding from the priesthood or religious life people who might still have many years of healthy, active life before them, despite their being HIV positive. The freedom dimension is also linked to the right to privacy. Obligatory testing of all candidates is undoubtedly an intrusion into a person's privacy. This would need to be justified by some compensating major positive gain to the common good. That needs to be proved rather than assumed, especially in view of the fact that anyone who has been tested, regardless of the test, often becomes the object of discrimination on the part of insurance companies and other financial institutions. Since such discrimination is the result of the testing policy of the diocese or religious congregation, it could be argued that the diocese or congregation is obliged to accept at least some responsibility for any financial loss incurred by a prospective candidate as a result of the ensuing discrimination.

Very deliberately I posed the initial question about compulsory testing not in terms of respect for freedom and privacy but in terms of living positively with AIDS. I have repeatedly insisted in this book that we are living in a 'time of AIDS'. Many would argue that in this 'time of AIDS', there is a special moral imperative (even a 'call from God') on dioceses and religious congregations to stand positively with those who are living with HIV/AIDS. At the very least, this would mean doing nothing that might seem to lend support to the tendency of many in society to marginalize people living with HIV/AIDS or which might increase the negative self-image and sense of alienation such marginalization can cause. In fact, it could even be argued that the acceptance within the diocesan priesthood or in a religious congregation of people with HIV/AIDS might provide a very powerful counter-witness to those who look on HIV/AIDS as only affecting 'people out there' and not really 'any of our concern', or who impose a stigma on anyone living with HIV/AIDS. Belief in the Church as a sign and instrument of the unity of the human family implies living in solidarity with people living with HIV/AIDS. Theologically, this has been captured in the expression, 'the Church has AIDS'. The presence of people living with HIV/AIDS in the priesthood and the religious life might help to bring home that important truth. At a meeting of Asian theologians on HIV/AIDS which I attended in Bangkok, I recorded in my diary that one of the theologians present, himself a religious, 'said that he dreamt of the day when every religious congregation would have HIV+ members who would be fully accepted and valued among them as religious. He believed that the congregations would be all the healthier for this.'

This last point, that in this 'time of AIDS' compulsory HIV testing for future priests and religious would give a counter-witness to the Gospel values we believe in clinches the argument for me. Therefore, I believe that 'living positively with AIDS' excludes such compulsory testing.

2. Is the Church living positively with AIDS when it opposes using condoms as a help towards preventing HIV infection?

There are two distinct issues which need to be treated quite separately here. One concerns condom use as a component in governmental HIV prevention programmes. The other concerns the use of condoms within marriage when one partner is HIV infected.

(a) Condom use as a component ingovernmental HIV prevention progammes

One of the health measures adopted in many countries has been to encourage non-HIV-infected people to use condoms if they are going to have sex with someone they cannot be absolutely sure is free of the virus. One phase of AIDS policy in the UK consisted in a massive and very expensive campaign along those lines. This policy later came in for strong criticism from the gay community on the grounds that, due to the government's unwillingness to appear supportive of gay sex, this campaign had diverted resources from where they were needed much more urgently, that is, to promote educational work among the gay community themselves since, at that point in time, they were the ones most at risk.

The Catholic Church has tended to object to this 'safer sex' educational policy and its promotion of condom use. It claims that such a campaign ignores the moral dimension of sexual activity, namely, its relational side. What is needed, it is argued, is to encourage young people to take the relational dimension of sex more seriously. Hence, the Church has refused to participate in any 'safer sex' campaigns and has limited its contribution to the 'relationship' agenda. One of the few slight modifications to this united front on the part of the Church is found in the first letter of the US Bishops' Conference on HIV/AIDS, 'The many faces of AIDS: a gospel response', issued on 11 December 1987. (The full text was published in Origins., 24 December 1987, pp. 481-9.) It contained the following passage:

Because we live in a pluralistic society, we acknowledge that some will not agree with our understanding of human sexuality. We recognise that public educational programs addressed to a wide audience will reflect the fact that some people will not act as they can and should; that they will not refrain from the type of sexual or drug abuse behaviour which can transmit AIDS. In such situations educational efforts, if grounded in the broader moral vision outlined above, could include accurate information about prophylactic devices or other practices proposed by some medical experts as potential means of preventing AIDS. We are not promoting the use of prophylactics, but merely providing information that is part of the factual picture. Such a factual presentation should indicate that abstinence outside of marriage and fidelity within marriage as well as the avoidance of intravenous drug abuse are the only morally correct and medically sure ways to prevent the spread of AIDS. So-called safe sex practices are at best only partially effective. They do not take into account either the real values that are at stake or the fundamental good of the human person, (p. 486)

This letter was issued by the Administrative Board of the US Bishops' Conference without being cleared by the Conference as a whole. When it appeared it provoked an outcry, not least among some of the bishops themselves, most notably Cardinal O'Connor of New York. In the light of this negative reaction, although this pastoral letter was never officially withdrawn, a replacement letter was put together. Entitled 'Called to compassion and responsibility: a response to the HIV/AIDS crisis', it appeared on 9 November 1989. It was issued in the name of the whole Bishops' Conference and gave no hint of toleration towards any preventive health policy involving the promotion or distribution of condoms. It simply asserted that 'advocating this approach means in effect promoting behaviour which is morally unacceptable'. Between the two letters and as a comment on the first letter, Cardinal Ratzinger had written to the papal nuncio, Archbishop Laghi. stating the real cause of the AIDS problem was 'the permissiveness which, in the area of sex as in that related to other abuses, corrodes the moral fibre of the people' (quoted in Richard L. Smith, Aids, Gays and the American Catholic Church, p. 66).

Another slight breach in the Catholic Church's united front opposing promotion of the use of condoms in HIV educational programmes was detected by some critics in the HIV/AIDS educational pack produced for schools by the Archdiocese of Edinburgh. This carried an imprimatur from the Archdiocese. According to a report in the Guardian (11 November 1995) the Congregation for the Doctrine of the Faith (CDF) 'criticised the pack for advocating the use of condoms for people who are HIV positive'. The actual wording found in the pack itself read:

Medically it has been shown that condoms do reduce the risk of infection but they are not 100% safe, and should not be seen as the answer to the problem. They do not make for safe sex. In marriage where one or both partners are HIV-positive, and the couple wish to continue to express their love sexually, they have a right and duty to use protection.

The CDF asked for the imprimatur to be withdrawn and for Catholic educational institutions to cease using the pack (cf. Briefing, 16 November 1995, p. 39).

A similar opposition to the promotion and use of condoms as a health measure has been characteristic of most bishops' conferences in developing countries too. As a result, many have publicly opposed any Government HIV/AIDS campaigns involving the promotion of condom-use for the purposes of 'safer sex'.

More recently in 1996 the Social Commission of the French bishops' conference produced a 235-page symposium on AIDS entitled SIDA: La societe en question (Paris, Bayard Editions/Centurion). The press coverage gave the impression that this constituted a major defence of the use of the condom in public health campaigns to prevent HIV transmission. In fact, the text is highly critical of such 'safer sex' campaigns and argues that at a public level they can do more harm than good. However, in a personal contribution to the symposium the president of the Social Commission, Bishop Albert Rouet, concedes that the use of condoms is 'understandable in the case of people for whom sexual activity is already an integral part of their lives and there is serious risk of their being infected by the virus' (p. 194, n. 49). However, he immediately adds that 'this course of action does not help to educate a person towards sexual maturity'. The general tone of the symposium reflects a conviction that the HIV/AIDS pandemic is an indication that there is something badly wrong in society. It argues that this underlying evil urgently needs to be tackled.

Although this document was less open to condom use than was suggested by press reports, it provided reporters with the opportunity of discovering that a number of bishops had independently adopted a similar line to Bishop Rouet. For instance, it was reported in The Tablet (24 February 1996, p. 272) that a 'less than absolute prohibition' stance had been taken by Cardinals Lustiger, Simonis and Eyt and the late Cardinals Decourtray and Coffy, as well as by Archbishop Aguilar and Bishops Bonfils and Cornet. Of particular interest is the statement of Bishop Alanis: 'If, with the use of the condom, we can save the harmony of the conjugal union, I believe that can be admissible.' Bishop Victor Guazzelli's comment to The Tablet is particularly noteworthy: 'It seems to me that if people are set on intercourse they at least have the obligation of not passing on disease and death, even if the only means possible to them is the use of the condom. This seems to be common sense.' I suspect many readers will say Amen' to that! After all, though there may be disagreements about how sexual loving is intended by God to be 'life-giving', there is surely no disagreement that God certainly did not intend it to be 'death-dealing'.

A number of points need to be made in this connection.

First of all, the anti-condom approach seems to ignore the fact that concern for bodily health is actually a moral issue. A government health authority would be failing in its duty if it did not do everything it could to safeguard and promote the health of its citizens. Hence, it needs to be recognized that in encouraging citizens to act in a way which offers less of a health risk a government is encouraging its citizens to behave more ethically. To oppose a government following this course of action would seem to be tantamount to obstructing a government in carrying out its moral obligations towards its citizens.

Some bishops have objected that to promote the use of condoms for 'safer sex' is to mislead people. The use of a condom does not guarantee there will be no risk of infection. Hence, a pro-condom campaign can give people a false sense of security. This objection is legitimate to the extent that it is engaging the issue precisely on health grounds. These bishops are claiming that, precisely as a health measure, this is not a good policy. A similar claim was made in a letter to The Tablet (25 November 1995, pp. 1508-9) by Dr Michael Jarmulowicz of the Guild of Catholic Doctors. The problem, however, is that this objection does not seem to be valid in the light of the best scientific evidence currently available. In a subsequent letter this is pointed out by Dr Michael Abbott, a consultant genito-urinary physician caring for people living with HIV/AIDS:

Two kinds of data (i.e. in vitro and in vivo) have been collected on the relationship between barrier methods of contraception and sexually transmitted diseases. The in vitro data generally show that high-quality latex condoms are impermeable to the passage of HIV and other organisms. As regard in vivo studies, what is clear is that consistent condom use confers substantial protection against HIV transmission but that inconsistent use carries considerable risk of HIV infection. (The Tablet, 9 December 1995, p. 1579}

Dr Abbott's point is corroborated by the Jesuit physician, Dr Jon Fuller, who is Assistant Director in the Clinical AIDS Programme at Boston City Hospital and Assistant Clinical Professor of Medicine at Boston University School of Medicine. Dr Fuller, too, is immersed in working with people living with the virus. In his HIV/AIDS: An Overview. (Chicago, National Conference of Priests, 1995), he writes:

For those who choose to engage in high risk behaviours despite all warnings, the routine use of latex condoms can decrease the risk of acquiring HIV There is no doubt that a number of factors can contribute to the failure rate of condoms, including improper timing in the use or improper technique in their application . . . Due to these multiple potential sources of error, the pregnancy rate for condoms has often been quoted as quite high, often in the neighbourhood of 10-15%. However, these statistics may represent the intermittent employment of condoms by inexperienced users. Studies with couples who use condoms correctly all the time have reported pregnancy rates as low as 2 %. More recent data from three studies evaluating the use of condoms to prevent HIV transmission from one infected member of a stable sexual relationship to the individual's uninfected partner suggest that consistent and correct use of latex condoms can significantly reduce the risk of acquiring HIV in this situation.

One observational study followed 245 HIV-discordant heterosexual couples (in which one member is HIV-infected and the other is not) for a median of 22 months; in all, the only risk for the uninfected member to become HIV-infected was intercourse with his or her infected partner. In retrospect, half of the group had used condoms 100% of the time, the other half had used them intermittently. As compared with 12 documented infections in the group using condoms intermittently, no infections were observed among those who used them consistently despite an estimated 15,000 episodes of intercourse.

In another study of 282 Greek prostitutes, no infections occurred over an observation period of two years among a group who had increased its use of condoms from 66% to 97% of the time. This change was also accompanied by a decrease in the frequency of syphilis from 17% to 3%, and in gonococcal infection from 14% to 0%.

A third study compared transmission rates from infected haemophiliacs to their sexual partners. Among 31 couples, 14 always used condoms, and 17 used them occasionally or not at all. Over an observation period of two years, there were 3 sero-conversions in the intermittent use group (a 17% transmission rate), compared with no infections in the consistent use group, (pp.'29-30)

Moreover, in his 1996 Distinguished Jesuit Lecture, AIDS Prevention and the Catholic Moral Tradition', at St Louis University Health Sciences Center, Dr Fuller mentions some new population-based data from Uganda and Thailand which also seem to indicate that condom-use can have a significant impact on HIV prevention. For instance, the Thai government's 100% Condom Campaign increased the use of condoms by commercial sex workers from 50 per cent to more than 94 per cent in the space of four years. Dr Fuller notes that this 'was accompanied by a reduction in sexually transmitted diseases - taken to be a surrogate marker for new HIV infections - from 6.5 per 1,000 to 1.64 per 3,000 (AIDS prevention: a challenge to the Catholic moral tradition', in America, 28 December 1996, pp. 13-20, at p. 18). In a country where HIV infection is running at 2 per cent of the population and where many married men frequent commercial sex workers, it is estimated that the success of the government's campaign has had a notable impact as a HIV prevention measure.

Dr Fuller accepts the the significance of the above evidence for government programmes which include condom-use as one component of their overall strategy. He believes that the studies cited 'demonstrate that these approaches can be part of the solution, that in real life situations they have significantly prevented HIV transmission and have saved many lives'. However, he repeats his warning that 'condoms cannot be taken as an absolute guarantee against infection during intercourse'. He states very clearly that 'condoms cannot make unsafe sex safe; they only make it less unsafe'. Nevertheless, he still insists that 'for those individuals who choose to engage in high risk activities, condoms can reduce the risk'.

In the light of this evidence, therefore, it would seem highly responsible for a government, as a part of its HIV educational programme, to encourage very strongly the use of condoms by those who, despite all warnings, insist on engaging in high-risk activities. The same would be true for individual doctors, including Catholic doctors. I fully agree with Dr Abbott's judgement when he writes:

I, and the vast majority of Catholic doctors I know, would have no hesitation whatsoever in recommending the use of condoms if a patient with HIV infection or any other sexually transmissible infection (whatever their marital status or sexual orientation) intended to have sexual relations with another person. (The Tablet, 9 December 1995, p. 1579)

It might be objected that the Church is in the business of moral education, not health education. Though there is some truth in that objection, it can also be dangerously misleading. Concern for health is a moral issue. It certainly loomed large in the ministry of Jesus. In fact, he seems to have placed health-care above the dictates of religious observance in some of his confrontations with the Pharisees. In the light of the evidence quoted by Dr Fuller regarding the health benefits of condom-use for prostitutes, I cannot help thinking that Jesus's angry reaction to the Pharisees when they objected to some of his cures on the Sabbath would have been equally in place when some misguided Filipino Church officials forced the Bethany Growth House drop-in centre for prostitutes to stop instructing their clients about the use of condoms (cf. AIDS in the Philippines: A Situation Analysis, JIC, 1994, p. 74).

Spokespersons for the Catholic Church often argue, with some justification, that 'safer sex' education is short-sighted and sells health concerns short. The only behaviour-change that will really prevent the spread of the AIDS virus is the observance of strict moral standards in the field of sexual ethics - 'no sex before marriage', 'no sex outside marriage' and 'no sex between same-sex couples'. However, the problem with this position is that the Church seems to be asking the state to present the Church's ethical teaching under the guise of health teaching. Obviously, the Church has every right to offer its ethical vision of good human relationships to the nation. It can even argue that following this vision is the road to better psychosomatic health. It is even legitimate for the Church to seek by democratic means to persuade the nation that it should embrace this kind of moral code as its agreed common morality, though here it would also need to insist that the state guarantees the freedom of those who, on conscientious grounds, cannot accept this common morality. However, what the Church cannot do is demand that the state should refrain from what it considers to be important features of health education simply because the behaviour involved runs counter to the Church's moral teaching. Such a demand would seem to be all the more unreasonable on the part of the Church when it is a case of moral teaching which does not seem to be accepted by a good proportion of the Church's membership.

It is not strictly accurate to say that the AIDS virus is being spread because of immoral behaviour. It is being spread mainly because people who have the virus are having sex with people who are not infected. That is a medically accurate reading of the situation. At this level, the only fully effective way of stopping the virus spreading is for such sexual behaviour to stop. Failing this, the next best thing is ensure that when such sexual behaviour occurs, the possibility of the virus being passed on is reduced as much as possible.

There is no way a government can step in and control all the sexual behaviour of its citizens, short of a George Orwell scenario. The permanent quarantining of all HIV positive persons would be making those infected the scapegoat for society's problem. It would be ignoring the fact that, in very many cases, the spread of the virus is due to the irresponsible behaviour of non-infected people. It is likely that a strict quarantine policy would only be possible in a highly totalitarian society. Yet it is remarkable that the quarantine policy followed in Cuba, contrary to the horror stories circulated about it, was conducted in an increasingly humane fashion. It also seems to have been extremely successful as a method of HIV prevention in the country. An interesting account of this policy has been written up by Nancy Scheper-Hughes, AIDS and the social body', in Social Science and Medicine., 1994, pp. 991-1003. As we seen already, those who are particularly at risk through such irresponsible behaviour are prostitutes and other young p eople, even children, who are victims of the sex industry. Almost certainly they would be targeted as the identifiable groups who would be made the scapegoats in any quarantine policy.

Probably the best a government can do in a democratic society is to launch an educational drive to encourage behaviour change. According to what we have considered already, this should have two components to it from a health point of view.

The first should be aimed at making people who know they are HIV positive more aware of their responsibility not to pass the virus on to others. It would point out that the most effective way to do this is to refrain from any sexual activity which would put others at risk. Failing that - and, in the case of a married couple when one is infected, that scenario need not imply anything morally questionable - the next best option is to make sexual activity as safe as possible through the use of a condom.

The second component should be directed at those who are uninfected by the virus. It should be aimed at making them more aware of their responsibility to take care of their own health. Hence, it will need to provide accurate information about how the virus is transmitted and what steps can be taken to prevent this transmission. Clearly, discussion of condom-use and the provision of accurate information about its effectiveness in preventing transmission of the virus will be part of this educational package.

However, such a policy should not be limited to purely health considerations. The moral climate of a country is very much the concern of a government, even though responsibility for this climate is shared by the whole community and, in a particular way, by the Churches and other religious bodies. Education in a positive sexual ethic should be a major concern of any government striving to prevent the spread of HIV infection. The argument of this book is that a Christian sexual ethics should be positive, joyful, life-loving, attractive and celebratory of our sexuality. If the Churches are willing to listen to and sympathize with the government's concern for all dimensions of a health education programme, there is more likelihood that the government will be supportive of personal relationship educational programmes which are based on such a positive sexual ethic.

(b) The use of condoms within marriage when one partner is HIV infected

When one partner is HIV positive or has advanced to full-blown AIDS, something new enters into their relationship which affects them both. Given the nature of HIV/AIDS, the infected partner might well feel an extra need for that love and reassurance which can be expressed so deeply in marital intimacy. And the other partner, if sensitive to that need, might well be all the more anxious to respond fully to that need. Since they have both made that high-level exercise of their freedom in giving themselves to each other in their marriage commitment, they believe that that commitment must be honoured by making love, especially now in this 'time of AIDS' in their lives. If their love-making is, as Vatican II teaches, a channel of God's love for each of them, they might well feel the need for it all the more at this crucial time.

However, they also recognize that safeguarding the health of the non-infected partner is a moral concern for both of them, if they are truly to respect each other as human persons. This serious moral obligation will take on an additional gravity if they have children who are likely to end up dependent on the care of the non-infected parent. A morality based on the dignity of the human person will have no difficulty in recognizing that such a couple may, and even should, use a condom if their love-making involves sexual intercourse. In doing so, they are being true to their dignity as human persons. They are, therefore, doing what is God's will for them.

Bob Vitillo recounts a very telling incident in this connection;

In one workshop which I was conducting in the Philippines, a religious sister stated that HIV-infected persons would simply stop having sexual relations if they really 'loved' their partners. One lay woman in the group quickly added the correction: 'You do not understand what married love involves. Sister. If my husband were infected with HIV I would need to continue my sexual relationship with him in order to express the fullness of my love for him and to receive strength and comfort from him on the long road ahead of us.' (unpublished address to National Catholic AIDS Ministry Conference, Chicago, 25 July 1994, p. 10)

Another HIV/AIDS scenario might be one in which the relationship between the couple is oppressive of the wife's freedom and far from the high level of equality and mutuality present in the above story. If it is the husband who is HIV positive in this case and if he demands intercourse as his right from his wife, sexual ethics must make it crystal-clear that this is not his 'right'. He has no right to endanger the health of his wife in this way. She has every right to refuse him, unless he is prepared to take adequate precautions. Obviously, in such a situation, it may be very difficult, even dangerous, for a wife to refuse her husband. To do so could put her at risk in a different way, as a result of her husband's violence towards here. A scenario like this presents a pastoral challenge to the Church on a number of fronts:

The Church's earlier understanding implicitly legitimated this kind of behaviour and attitude on the part of a husband. Today we recognize that this violates the Church's own criterion of the dignity of the human person. Hence, every effort needs to be made to disabuse both husbands and wives of this earlier understanding and so reduce the harm it is still causing, especially to women, within marriage.
The criterion of the dignity of the human person means that, if a wife feels she has to agree to sex in the kind of scenario envisaged above, any Church official who told her that it would better if her husband did not use a condom would be perpetrating a serious injustice against her.
As long as a lower-level interpretation of marriage is still in practical operation, it would seem that an important dimension of the Church's work of marriage preparation and continuing support for couples would be in the area of assertiveness-training for wives. This might be more necessary in some cultures than in others.

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