STOPPING THE SPREAD OF HIV/AIDS
Mons. Jacques Suaudeau, Pontifical Council for the Family
Prophylactics or Family Values?
Every year, towards the end of December, the world rediscovers the harsh reality of the HIV/AIDS epidemic following the annual international conference on the subject. This year the UNAIDS report on the growth of the epidemic was perhaps even more worrying than in past years, particularly because of the grave projections for sub-Saharan Africa implied by this report and for its survival in the new century.
At the end of the 20th century, according to the data provided by UNAIDS, 2.6 million people in the world died this year because of AIDS.(1) This is the highest total recorded since the beginning of the HIV/AIDS epidemic, despite the development of the antiretroviral therapy which has controlled the spread of the disease in wealthier countries. 5.6 million new cases were reported in the world this year. There are 32.4 million adults and 1.2 million children infected by HIV/AIDS in the world today; 95% of them live in poor or developing countries.
These figures are particularly shocking when we consider that today the AIDS tragedy specifically affects sub-Saharan Africa. The conference in Lusaka, Zambia, held from 12 to 16 September 1999, drew attention to the unfortunate deterioration of the situation.(2) In fact, 70% of the world's seropositivethat is, 23.3 million peoplelive in sub-Saharan Africa, although its entire population accounts for only 10% of the world's total. The majority will die in the next 10 years. There is an 8% prevalence in the adult population (0.25% for Western Europe, 0.13% for North Africa and the Middle East). Since the start of the epidemic, 34 million people in sub-Saharan Africa have been infected with HIV. Of these, 11.5 million are already dead (83% of. those who have died of AIDS since the beginning of the global epidemic). In 1998 AIDS was responsible for 2.2 million deaths in sub-Saharan Africain comparison with the 200,000 caused by war.(3) Life expectancy at birth, which in South Africa had risen from 44 years in the 1950s to 59 in the 90s, will drop to 45 years between 2005 and 2010.(4) These deaths represent the younger sector of the population, which was educated, professionally trained or taught in schools.(5) They were the hope of these poor countries. Many of them were young mothers with small children. Today it is they who are the cause of the terrible problem of AIDS orphans. 95% of the 11.2 million AIDS orphans are African.(6)
Church has cared for AIDS patients from the start
If 7 out of 10 individuals infected with HIV this year live in sub-Saharan Africa, the proportion of children increases to 9 out of 10. 570,000 children under 14 years of age have been infected with HIV/AIDS this year in sub-Saharan Africa, and 90% of these were born of seropositive mothers.
These data give a true picture of the tragedy: the HIV/AIDS epidemic is devastating Africa and jeopardizing the continent's future. On 10 January this year, the UN Security Council met specifically to discuss the problem(7) and called the HIV/AIDS epidemic the most serious factor in the economic and political destabilization of Africa, "a security crisis", in the words of Vice-President A. Gore.(8) "The epidemic has become more destructive than a war", said Dr Peter Piot, Director of UNAIDS.
The Catholic Church has not been indifferent to this situation. Far from it. Since the start of the epidemic, the Catholic Church has been present with her hospitals, treatment centres, parishes, the service of men and women religious, local aid organizations for the sick and concern for their problems. In Africa she has been in the forefront of the fight against HIV/AIDS. For this reason, the Pontifical Council for the Family, during its courses on family and ethical issues, with the collaboration of the Episcopal Conferences, has held several meetings with the doctors and nurses involved in the fight against AIDS. Most of these meetings were held in the countries of sub-Saharan Africa affected by the epidemic.
We must remember that the Catholic Church's commitment has, as always, been discreet and effective. We must recognize, above all, the admirable dedication and extraordinary generosity of the many people we have seenin Uganda, Kenya, Tanzania, Ghana, Cote dIvoire, Benin, Central African Republic, Burkina Fasovisiting AIDS patients in their homes, bringing them human assistance, medical treatment and, frequently, food and drink. To understand the reality of AIDS in these countries, one must follow the volunteer workers on their rounds, as we did, and see them entering dark houses, bending with compassion over a poor emaciated woman on the verge of death, surrounded by three or four children who will have nothing left tomorrow, not even their mother.
We must pay due respect to those women religious who have taken in so many children orphaned by AIDS and provided them with shelter, food, education and professional training by begging funds right and left and relying on a minimum of public assistance and the meagre contributions of international institutions. We must respect these lay men and women, often from other continents, who have given hope, dignity of life and food to so many women infected with AIDS and rejected by everyone as "dirty". Here we have seen Christ suffering, Christ despised, stigmatized and rejected, Christ sick and visited by no one, Christ dying of hunger and thirst. We sensed their horrible loneliness and the terrible feeling of being given up for lost. But we also saw Christ visiting the sick, comforting the suffering, embracing AIDS victims and taking responsibility for, their children who are now orphans.
Recalling the serene and smiling faces of so many African men and women we saw each day involved without fanfare in this harsh struggle against the devastation of the HIV/AIDS epidemic, we were saddened by the recent statements several people made to the press, which provoked such an outcry during their brief trips to a few African countries. In these statements the Catholic Church was basically accused of being "indifferent" to the AIDS tragedy in Africa.
It is true that when someone sees the appalling reality of the AIDS problem in Africa for the first time with his own eyes, it is natural to feel shocked and indignant. A guilty party is sought, and it is often those involved in remedying the situation who are blamed, while others are content to criticize.
Family values guarantee true human victory
Thus the Catholic Church has been accused of lacking a sense of reality and of being irresponsible about the HIV/AIDS epidemic in Africa because of her position regarding the use of prophylactics to prevent sexual contamination.
At various meetings the Pontifical Council for the Family has continually recalled the Catholic Church's message about this difficult question of preventing HIV/AIDS. This message is based, in a few words, on "the value of the family". What is at stake here is a vision of man and woman, of their dignity, of the meaning and significance of sex, as presented in this Council's document on human sexuality.(9) Wherever there is true education in the values of the family, of fidelity, of marital chastity, the true meaning of the mutual gift of selfand this seriously involves the State as welland wherever the intrusive forms of promiscuity are overcome, man will achieve a human victory, even over this terrible phenomenon.
In the prevention of any epidemic a distinction can be made between means that are properly preventive and those of "containment". With malaria, for example, a disease comparable to HIV/AIDS because of its effect on the population and the number of deaths it causes, the preventive measures developed over the yearsespecially in combatting the anopheles mosquitowere those of "containment", because they did not go to the roots of the disease. Effective in theory, these measures proved ineffective in practice because it is impossible to destroy all the larvae, drain all the lakes or prevent people from having uncovered water supplies.
Another example is typhoid fever. Prevention was effective here, because it was possible to convince people to be careful about their sources of drinking water. This was real prevention, because the mistaken attitude that had been responsible for people's contamination could be corrected.
If people really want to prevent AIDS, they must be convinced to change their sexual behaviour, which is the principal cause of the infection's spread. Until a real effort is made in this regard , no true prevention will be achieved.
The prophylactic is one of the ways to "contain" the sexual transmission of HIV/AIDS, that is, to limit its transmission.. However everyone recognizes that "perfection" in this area does not and cannot exist. Without going into the possibility of latex, condoms splittingor slipping which is always possible during the sexual act, it is clear that the prophylactic is only effective "when it is used correctly",(10) and only then: an optimal condition that in fact leaves ample room for less than optimal conditions.(11) Details on the numerous cases of prophylactic failure have been widely publicized elsewhere.(12) The truth is that for various reasons "prevention" has been equated with "the proper use of prophylactics", without their effectiveness in the HIV/AIDS epidemic having been statistically proved or reallybeing provable, because of the multiple factors influencing the spread of the epidemic.
This "decision of principle" has deliberately obscured what has been known for some time about the relative effectiveness of the prophylactic as a contraceptive.(13) In fact, statistics in this area indicate almost 15 failures per 100 sexual acts "protected" by condoms. We are asked to believe that the HIV virus, 450 times smaller than spermatozoa, can almost always be magically blocked by a condom, without taking into account that spermatozoa themselves can pass through the latex barrier in 15 out of 100 completed sexual acts. The only statistically valid study on the effectiveness of prophylactics in fighting HIV/AIDS is that of the "Groupe dEtudes Europeen".(14) However this study examines stable couples, who are serodiscordant(15) and free of genital infections, on the basis of the situation in Europe where, in any case, the sexual transmission of the virus is more than contained. Further statisticswhich should be prudently interpretedconstantly show a failure rate of at least 10% (10 failures out of 100 prophylactics used).(16)
Lastly, according to recent information from several researchers at London's University College Medical School,(17) the publicity given to the condom in the fight against HIV/AIDS could have an effect contrary to what is desired inasmuch as such publicity might lead people to riskier sexual behaviour because of the sense of safety they feel when using a prophylactic.
AIDS epidemic cannot be stopped with condoms alone
Thus there is no hope of halting the HIV/AIDS epidemic with condoms alone, just as there is no hope of preventing a river from flooding by using sandbags when the main dikes have collapsed. One can only hope to contain it.
In any case, the Church's position on the prevention of HIV/AIDS is not at this technical health-care level. She turns instead to the human and anthropological root of the problem, that is, to the level of respect for human sexuality, to the level of the values that determine the human growth of individual members of the human race. If the HIV/AIDS epidemic has assumed such proportions in the countries of sub-Saharan Africa, it is because it has found favourable conditions for spreading in this way: unemployment, poverty, the condition of refugees, civil wars, the lack of political authority or health-care structures, corruption, the concentration of the poor in large urban areas, the growth of occasional or permanent prostitution. Moreover, the condition of women, who are subject to the will of their husbands on pain of rejection with the gravest social consequences, in a certain way explains why it is women who, in the various countries of sub-Saharan Africa, are today the worst hit by the HIV/AIDS infection (12-13 women for every 10 men).(18) The recurrence of sexually transmitted diseases that lead to HIV in the female organism(19) explains the rest. The prevention of AIDS must act at this basic, social, value level, if it is to be effective.(20)
The most radical prevention of HIV/AIDS, the one which is absolutely effective and which no one can deny, is sexual abstinence for adolescents before marriage and conjugal chastity in marriage. This is the Church's message. Merely to ask adolescents to use prophylactics in their sexual experiences means continuing to feed the vicious cycle of sex which is at the root of the serious pandemic in sub-Saharan Africa. It is an illusion to equate the effectiveness of the HIV/AIDS battle with the number of prophylactics distributed in a given population.
Today we are presented with the cases of Uganda and Thailand(21) where international and national efforts to encourage the use of prophylactics are supposed to have had success.
In the case of Thailand, the effort of the health-care authorities was focused on prostitutes and their clients. The use of condoms had particularly good results for these people with regard to the prevention of sexually transmitted diseases.(22) However it is unclear whether or not the promotion of condoms in this country has had an effect on the overall advance of the HIV/AIDS epidemic.(23) The use of prophylactics in these circumstances is actually a "lesser evil", but it cannot be proposed as a model of humanization and development. Perhaps Thailand's authorities might have asked themselves first about the. reasons for the particular growth of prostitution in their country.
The case of Uganda seems a better example, since efforts have been made on all fronts and have effectively reached the very roots of the epidemic. In the study presented by UNAIDS,(24) questions were asked about the factors that led to a decline of the epidemic in Uganda.(25) The spread of HIV dropped from 45% to 35% in the men examined at the clinics for sexually transmitted diseases in Kampala, and from 21% to 5% in the pregnant women examined in Jinja between 1990 and 1996. If the questionnaires show that sexually active men and women use prophylactics more frequently, the factor we consider more important is the change in the sexual behaviour of young people, who are delaying their first experience of sexual relations (56% of boys from 15 to 19 said in 1995 that they had had no sexual relations, as compared with 31% in 1989, and 46% of girls said the same thing in 1995, as compared with 26% in 1989), and are marrying at an older age; another important factor is the decrease in sexual relations outside marriage (it fell from 22.6% in 1989 to 18.1 % in 1995 for men).(26)
To conclude these observations on prevention of the HIV/AIDS epidemic in sub-Saharan Africa and the role that the Catholic Church has played in this battle, we should mention several exemplary programmes, among others, that have been created for adolescents and
young people in these countries. In Uganda, Tanzania and Nigeria groups of young people have been organized by Catholic women religious, priests and lay people who are concerned for them. These groups are dedicated to the fight against HIV/AIDS(27) and are called by the significant names: "Youth Alive" and "Youth for Life". In these informal groups, which are independent of any government or state organization, boys and girls of 16 to 18 years of age are involved in fighting HIV/AIDS among their classmates and companions, with a commitment to sexual continence until marriage and to conjugal chastity after marriage.
These groups are not theoretical projects. They really exist and have existed for years, discreetly and effectively. We had an opportunity to meet them and to talk with young people who are "normal", smiling, happy, interested in music and football, lovers of life but not of prophylactics. These groups do not ask for money: they ask for love, patience, time, dedication and faith from those who guide them.
Undeniably, this is the model to be followed: it is certainly not an easy model, but it is fully human, based on faith and hope and not on something made of latex to be distributed. With the millions of dollars spent on the prophylactic industry, far more could have been done for the young people of Africa, for their education, for their support and for effective prevention of contracting HIV/AIDS.
The Catholic Church believes in the value of the human person and his resources. She believes that "man infinitely surpasses man", as Blaise Pascal said, because he is created in the image of God, because "God created man [and woman] in his own image" (Gn 1:27). In the area of HIV/AIDS, we have treated man as if he were an animal being treated by a veterinarian, forgetting all, the energies he can bring to bear when he is convinced that it is worthwhile acting for something necessary. Just as Malthus was mistaken(28) in his projections because he had not considered that man could multiply his resources by using his genius, an error has been committed in dedicating every effort to the "containment" of HIV/AIDS by using an artificial barrier unworthy of human sexuality and unworthy of the human person.
One can understand the motive that spurs health authorities to distribute prophylactics to prostitutes and their clients. But the prevention of HIV/AIDS must be more than this; it must be moved to another level and attack the true social, economic, political and moral roots of the epidemic. This is not impossible; it is only necessary to broaden one's horizon and to have greater respect for people. "Youth Alive" and "Youth for Life" have made this choice. It is an option for the future of a continent that might otherwise be hopeless.
1. M. Salter, "AIDS Now World's Fourth Biggest Killer", Science 1999, 284 (5417):1101.
2. E. Favereau, "Sida en Afrique: un bilan amer", Liberation, 17 September 1999.
N. Herzberg, "Dans une immense solitude, I'Afrique meurt d'abord du sida", Le Monde, 14 September 1999, p. 1.
N. Herzberg, "L'epidemie de sida est sur le point d'aneantir les rares acquis du developpement en Afrique", Le Monde, 16 September 1999, p. 4.
3. P. Benkimoun, N. Herzberg, "Le sida est devenu la premiere cause de mortalite en Afrique", Le Monde, 14 September 1999, p. 6.
4. Life expectancy in Zambia has fallen from 64 to 47 years. In this country, a 15-year-old boy has a 60% chance of dying from AIDS.
D. Logie, "AIDS Cuts Life Expectancy in Sub-Saharan Africa by a Quarter", British Medical Journal, 1999, 319 (7213):806.
5 "AIDS: Teachers Dying in Central Africa", Current Concerns, October 1999, n. 10/99, p. 7.
"A quoi sert-il de construire des ecoles en Afrique si les professeurs meurent comme des mouches?", Le Monde, Economie, 14 September 1999, p. III.
6. N. Herzberg, "Les orphelins de Cairo Road", Le Monde, 30 September 1999, p. 14.
7. Afsane Bassir Pour, "LesEtats-Unis saisissent I'ONU du probleme du SIDA en Afrique", Le Monde, 12 January 2000, p. 3.
8. "Africa's AIDS Crisis", International Herald Tribune, 13 January 2000, p. 8.
9. The Truth and. Meaning of Human Sexuality: Guidelines for Education within the Family, Rome, 1995.
10. UNAIDS: Sexual Behavioural Change for HIV: Where have theories taken us?, UNAIDS Best Practice Collection/99, 27E, June 1999, www.unaids.org., p. 20.
11. W. Cates, A. R. Hinman, "AIDS and Absolutismthe Demand for Perfection in Prevention", The New England Journal of Medicine, 327 (7):492-494.
W. L. Roper, H. B. Petersen, J. W. Curran, "Commentary: Condoms and HIV/STD PreventionClarifying the Message", American Journal of Public Health, 83 (4):501-503.
12. K. April, R. Koster, G. Fantacci, et al., "Qual e il grado effettivo di protezione dall'HIV del preservativo?", Medicina e Morale, 1994, 44 (5):903-905.
R. Kirkman, "Condom Use and Failure", The Lancet, 1990, 336 (8721):1009.
R. Kuss, H. Lestradet, "SIDA: communication, information et prevention", in Le SIDA, propagation et prevention, Rapports de la commission VII de I'Academie Nationale de Medecine, Editions de Paris, 1996, pp. 12-55.
J. Suaudeau, "Le 'sexe sur' et le preservatif face au defi du Sida", Medicina e Morale, 1997 (4):689-726.
13. W. R. Grady, M. D. Hayward, J. Yagi, "Contraceptive Failure in the United
States: Estimates from 1982 National Survey of Family Growth", Family Planning Perspectives, 1986, 18 (5):200-209.
S . Jejeebhoy, "Measuring Contraceptive Use-Failure and Continuation: An Overview of New Approaches, in Measuring, the Dynamics of Contraceptive Use", United Nations, New York, 1991, pp. 21-51, tables 3, 5.
D. M. Potts, G. I. M. Sawyer, "Effectiveness and Risks of Birth-Control Methods", British Medical Bulletin, 1970, 26 (1):26-32.
E. F. Jones, J. D. Forrest, "Contraceptive Failure Rates Based on the 1988 NSFG [National Survey of Family Growth]", Family Planning Perspectives, 1992, 24 (1):12-19.
M. P. Vessey, M. Lawless, D. Yeates, "Efficacy of Different Contraceptive Methods, The Lancet, 1982, 1 (8276):841-842.
World Health Organization, Communicating Family Planning in Reproductive Health: Key Message for Communicators, WHO, 1997, p. 18.
14. I. De Vincenzi, "Comparison of Female to Male and Male to Female Transmission of HIV in 563 Stable Couples", British Medical Journal, 1992, 302:809-813.
I. De Vincenzi, for the European Study Group on Heterosexual Transmission of HIV, "A Longitudinal Study of Human Immunodeficiency Virus Transmission by Heterosexual Partners", The New England Journal of Medicine, 1994, 331 (6):341-346.
15. In the situation of serodiscordant HIV couples, the most important factor affecting the transmission of HIV seems not to be the use or non-use of a condom, but the sexual behaviour of the partners and the presence or absence of sexually transmitted diseases. In his statistics for 1987, N. Padian showed that the risk of HIV contamination basically depends on the number of partners and the number of sexual acts with an infected partner.
N. Padian, L. Marquis, D. P. Francis, et al., "Male-to-Female Transmission of Human Imunodeficiency Virus", Journal of the American Medical Association, 1987, 258 (6):788-790.
16. P. C. Gotzsche, M. Hording, "Condoms to Prevent HIV Transmission Do Not Imply Truly Safe Sex", Scandinavian Journal of Infectious Diseases, 1988, 20 (2), pp. 233-234.
H. Hearst, S. Hulley, "Preventing the Heterosexual Spread of AIDS: Are We Giving Our Patient the Best Advice?", JAMA, 1988, 259 (16):2428-2432.
J. Kelly, "Using Condoms to Prevent Transmission of HIV: Condoms Have an Appreciable Failure Rate", British Medical Journal, 1996, 312 (7044):1478.
J. A. Kelly, J. S. St. Lawrence, "Cautions about Condoms in Prevention of AIDS", The Lancet, 1987, 1 (8258):323.
S. H. Vermund, Editorial "Casual Sex and HIV Transmission", American Journal of Public Health, 1995, 85 (11):1488-1489.
J. T. Vessey, D. B. Larson, J. S. Lyons, et al., "Condom Safety and HIV", Sexually Transmitted Diseases, 1994, 21 (1):59-60.
S. Weller, "A Meta-Analysis of Condom Effectiveness in Reducing Sexually Transmitted HIV", Social Science Medicine, 1993, 36 (12):1365-1644.
17. J. Richens, J. Imrie, A. Copas, "Condoms and Seat Belts: The Parallels and the Lessons", The Lancet, 2000, 355 (9201):400-403.
18. AIDS Epidemic Update: December 1999, UNAIDS, p. 16.
19. M. S. Cohen, "Sexually Transmitted Diseases Enhance HIV Transmission: No Longer an Hypothesis", The Lancet, 1998, 351 (Suppl. III): SIII5-SIII7.
20. Studies in Mwanza, Tanzania (Grosskurth et al.), and, more recently, in the Rakai districts of Uganda (Waver et al.) have impressively shown that HIV infection can be controlled and prevented in populations by the treatment of sexually transmitted diseases alone, without other anti-HIV/AIDS measures.
H. Grosskurth, F. Mosha, J. Todd, "Impact of Improved Treatment of Sexually Transmitted Diseases on HIV Infection in Rural Tanzania", The Lancet,
1995, 346, pp. 530-536; The Lancet, 1997, 350, pp. 1805-1809.
M. J. Waver, N. K. Sewankambo, D. Serwadda, et al., "Control of Sexually Transmitted Diseases for AIDS Prevention in Uganda: A Randomized Community Trial", The Lancet, 1999, 353 (9152): 515-535.
21. W. Phoolcharoen, "HIV/AIDS Prevention in Thailand: Success and Challenges", Science, 19 June 1998, 280 (5371):1873.
22. R. S. Hanenberg, W. Rojanapithayakorn, P. M Kunasol, D. C. Sokal, "Impact of Thailand's HIV-Control Programme as Indicated by the Decline of Sexually Transmitted Diseases", The Lancet 1994, 344 (8917):243-245.
23. J. Richens, J. Imrie, A. Copas, "Condoms and Seat Belts", ibid., p. 401.
24. A Measure of Success in Uganda, UNAIDS Case Study, May 1998.
25. G. Asiimwe-Okiror, A. A. Opio, J. Musinguzi, E. Madraa, G. Tembo, M. Carael, "Changes In Sexual Behavior and Decline in HIV Infection among Young Pregnant Women in Urban Uganda", AIDS, 1997, 11:1757-1764.
26. These data are supported by a recent study on the differences in sexual bahaviour of the population of four African cities, where the prevalence of AIDS differs widely (from 3.3% in Cotonou, Benin, to 31.9% in Ndola, Zambia). This study highlights, among other things, the relationship between the precocity of the first sexual relations among girls and the prevalence of HIV in their group. The adolescents of Kisumu and Ndola, in particular, have precocious relations with older men, and the prevalence of transmittable sexual diseases among them is higher than in the other cities studied.
J. Cohen, "AIDS Researchers Look to Africa for New Insights", Science, 2000, 287 (5455):942-943.
Differences in HIV Spread in Four Sub-Saharan African Cities, UNAIDS, Lusaka, 14 September 1999.
27. L. McSweeny, AIDS, Your Responsibility, Ambassador Publications, 1991; L. McSweeny, Changing Behaviour. A Challenge to Love, Ambassador Publications, 1995; I. D. Campbell, G. Williams, AIDS Management: An Integrated
Approach, ACTION AID, 1994.
28. D. B. Marron, "Biology, Economics, and Models of Humanity's Future: What Have We Learned since Malthus?", Perspectives in Biology and Medicine, 1999, 42 (2):195-206.
Weekly Edition in English
19 April 2000, page 9
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