The church & AIDS in Africa: condoms & the culture of life.

As a young physician, I often second-guess myself. In practicing medicine such self-criticism is warranted, even obligatory, because a wrong diagnosis can lead to misguided therapy and may end in death. After working at a Catholic hospital in the small sub-Saharan country of Swaziland, however, there is one diagnosis I pronounce with uncharacteristic certitude: AIDS.

The typical patient is a young woman between eighteen and thirty years of age. She is wheeled into the examining room in a hospital chair or dragged in, supported by her sister, aunt, or brother. She is frequently delirious; her face is gaunt; her limbs look like desiccated twigs. Surprisingly, the young woman is already a mother many times over, yet she will not live to see her children grow up. More shocking still, she is married; her husband infected her with the deadly virus.

This is the reality: a married woman living in Southern Africa is at higher risk of becoming infected with HIV than an unmarried woman. Extolling abstinence and fidelity, as the Catholic Church does, will not protect her; in all likelihood she is already monogamous. It is her husband who is likely to have HIV. Yet refusing a husband's sexual overtures risks ostracism, violence, and destitution for herself and her children. Given these realities, isn't opposing the use of condoms tantamount to condemning countless women to death? In the midst of the AIDS epidemic, which has already killed tens of millions and preys disproportionately on the poor, the condom acts as a contra mortem and its use is justified by the Catholic consistent ethic of life.

At least, this is the view of many Catholics at the front lines of the global HIV battle. Catholic organizations mercifully provide around 25 percent of the care AIDS victims receive worldwide. Many of the clergy and laity involved in treating people with AIDS, who otherwise fully ascribe to the church's teachings on sexual ethics and the sanctity of marriage, nevertheless endorse the use of condoms. They argue that the preservation of human life is paramount. Fr. Valeriano Paitoni, working in Sao Paulo, Brazil, summarized this perspective: "AIDS is a world epidemic, a public-health problem that must be confronted with scientific advances and methods that have proven effective," he says. "Rejecting condom use is to oppose the fight for life."

Bishop Kevin Dowling of South Africa has also been imploring the Vatican to view condom use as curtailing the transmission of death rather than precluding the transmission of life. In South Africa, 5.3 million people are infected with HIV and 25 percent of all pregnant women test positive for the virus. Dowling prays that the Holy Spirit will intervene to change minds in Rome. He believes Pope Benedict XVI's view on the use of condoms would change, "if his visits to poor countries were done in such a way that he could sit in a shack and see a young mother dying of AIDS with her baby." Not long ago, Belgian Cardinal Godfried Danneels stated on Dutch television that although sex with a person infected with HIV is to be avoided, "if it should take place, the person must use a condom in order not to disobey the commandment condemning murder, in addition to breaking the commandment which forbids adultery." He added: "Protecting oneself against sickness or death is an act of prevention. Morally, it cannot be judged on the same level as when a condom is used to reduce the number of births."

Unfortunately, the Vatican has not budged. Condoms thwart conception; therefore, by the 1968 encyclical Humanae vitae, their use is proscribed. End of debate. In a 2003 Vatican document titled Family Values Versus Safe Sex, the use of condoms in HIV-prevention programs was forcefully rejected:

   The Catholic bishops of South Africa, Botswana, and Swaziland
   categorically regard the widespread and indiscriminate promotion of
   condoms as an immoral and misguided weapon in our battle against
   HIV/AIDS for the following reasons. The use of condoms goes against
   human dignity. Condoms change the beautiful act of love into a
   selfish search for pleasure--while rejecting responsibility. Condoms
   do not guarantee protection against HIV/AIDS. Condoms may even be one
   of the main reasons for the spread of HIV/AIDS.

Cardinal Alfonso Lopez Trujillo, head of the Pontifical Council for the Family, has elaborated on the latter point: "In the case of the AIDS virus, which is around 450 times smaller than the sperm cell, the condom's latex material obviously gives much less security ... to talk of condoms as 'safe sex' is a form of Russian roulette." Trujillo called on ministries of health to require "a warning, that the condom is not safe" on packages distributed worldwide.

Although it is true that condoms are not 100-percent effective in preventing HIV infection, they do reduce the risk of transmission significantly. Comparing condom use to a suicidal dare, as Cardinal Trujillo does, is scientifically inaccurate and socially irresponsible. A preponderance of medical research demonstrates that condoms help prevent the spread of HIV. For example, the European Study Group on Heterosexual Transmission of HIV followed 124 discordant couples (in which only one of the pair is infected with HIV) who consistently used condoms. Over a two-year period and roughly fifteen thousand sexual acts, none of the HIV-negative partners contracted the virus. Thai investigators examining the impact of condom use among the military reported that new infections dropped from 12.5 percent in 1993 to 6.7 percent in 1995. The number of new HIV infections in Thailand plummeted after the introduction of a "100-percent condom use" program. Uganda earned its reputation as a paragon of HIV prevention for its now-famous ABC program: Abstain, Be faithful, and Consistent, Correct use of Condoms. Following the implementation of ABC, HIV infection in Uganda decreased from between 15 and 20 percent of the population in the early 1990s to 5 percent in 2003. A comparative analysis of Ugandan population-based surveys in 1989 and 1995 concluded that delaying the age of first sexual encounters, decreasing the number of casual partners, and increasing condom use all contributed to Uganda's success. More recently, though, HIV has been on the rise in Uganda. Current data estimate 7 percent of the population is infected with the AIDS virus. Some advocacy groups attribute this upswing to a national condom shortage orchestrated by the Ugandan government under pressure from the Bush administration. The Health Ministry of Uganda refutes this allegation, stating that delays in the distribution of condoms have been the result of enhanced inspection of shipments after a batch of Chinese condoms was purportedly discovered to be faulty.

Of course, never having sex will significantly reduce the risk of contracting a sexually transmitted disease. (It will not, though, completely eliminate the risk of contracting HIV, since the virus is also transmitted via blood products, birthing, and breastfeeding.) But the Vatican must be made aware that abstaining from sex is not a choice that many women living in the developing world have. To preach fidelity and abstinence assumes that a woman can determine with whom she sleeps and when--a grave misunderstanding of the relations between the sexes in places where women are sometimes betrothed at birth or sold for cattle. How can the Vatican continue to prohibit the use of a life-saving intervention amid a pandemic of unprecedented proportions? By reflexively invoking Humane vitae whenever the condom issue arises, the church has tragically misdiagnosed the moral problem at hand.

Benedict XVI made his first comments as pope regarding condom use at a June 2005 papal audience. His listeners included bishops from South Africa, Swaziland, Botswana, Namibia, and Lesotho. After reviewing the importance of catechesis and recruiting African men to the priesthood, the pope turned his attention to AIDS: "It is of great concern that the fabric of African life, its very source of hope and stability, is threatened by divorce, abortion, prostitution, human trafficking, and a contraception mentality." He emphasized that contraception leads to a "breakdown in sexual morality." In the speech, the pope made a diagnosis: condoms increase sexual immorality, and sexual immorality increases the spread of AIDS. The logical treatment for sexual immorality is Christian marriage, fidelity, and chastity. Cardinal Javier Lozano Barragan, president of the Vatican's Council for Pastoral Assistance to Health Care Workers, had reached a similar conclusion in his Message for World AIDS Day (December 1, 2003): "We have to present this [lifestyles emphasizing marriage, fidelity, and chastity] as the main way for the effective prevention of infection and spread of HIV/AIDS, since the phenomenon of AIDS is a pathology of the spirit."

Fidelity in marriage and abstinence for everyone else would be the only indicated intervention if a "pathological spirit" were the only cause of AIDS. Unfortunately, many victims of HIV are blameless. Currently, 25 million HIV-infected individuals and 12 million AIDS orphans are living in sub-Saharan Africa. The communities hardest hit by AIDS are among the world's most impoverished. Sub-Saharan Africa, which has the world's lowest per capita annual income ($450 US), and where half of all individuals live in extreme poverty (earning less than a dollar a day), is ground zero of the epidemic. Over 70 percent of all infections, 80 percent of all AIDS-related deaths, and 90 percent of all AIDS-orphanings occur here. And with over six thousand new infections per day, the epidemic shows no signs of abating.

Obviously, the poor are limited in their access to education and to health services. Ignorance kills. When accurate information is not available, myths multiply. Surveys from forty countries indicate that more than 50 percent of young people aged fifteen to twenty-four have serious misconceptions about how HIV/AIDS is transmitted. Research by the Nelson Mandela Foundation has shown that 35 percent of twelve- to fourteen-year-olds thought that sex with a virgin could cure AIDS, or were unsure whether or not that statement was true. In other impoverished nations, AIDS is thought to be spread by witchcraft, mosquito bites, or through polio vaccination.

As already noted, the church in Africa is facing a grim reality even when it comes to sex in marriage. According to UNICEF, teenage brides in some African countries are becoming infected with the AIDS virus

at higher rates than sexually active unmarried girls of similar ages. That's because young brides are acquiring HIV from their husbands, who tend to be many years older and were infected before marriage. Clearly, abstinence and fidelity prevention strategies will not reliably protect these women. The result is reflected in the epidemiology of the disease: more than two-thirds of new HIV infections among people aged fifteen to twenty-five occur among women. In some areas of Africa, girls are five to six times more likely to be HIV-positive than boys of the same age.

The suffering associated with these alarming trends is difficult to comprehend. Stephen Lewis, UN special envoy for HIV/AIDS in Africa, summarized it this way: "To this catalogue of horrors, there must be added, in the case of Africa, that the pandemic is now, conclusively and irreversibly, a ferocious assault on women and girls." What has been called the "feminization of poverty" is a particularly lethal phenomenon in conjunction with AIDS. Gender discrimination in much of the world prohibits women from owning property or earning a living wage. To survive these harsh economic realities, many women are forced into prostitution. Paul Farmer, the Harvard physician and anthropologist, has noted that the women he interviewed in Haiti "were straightforward about the nonvoluntary aspect of their sexual activity: in their opinions, poverty had forced them into unfavorable unions. Under such conditions, one wonders what to make of the notion of 'consensual sex.'"

In Africa, the legacy of colonial racism, and especially of apartheid, still plays a role in determining one's risk of contracting HIV. In South Africa, a migrant labor system separated husbands from wives and made normal family life impossible. That pattern continues in the mining industry today, where the conflation of harsh working conditions, separation from wife and family, and the invariable proximity of brothels facilitate the spread of HIV from sex worker to laborer, and thence to his wife and children.

Acknowledging the role that poverty, racism, and gender inequality play in fueling the spread of AIDS in no way diminishes the need for personal responsibility and moral restraint. Indeed, even the correct and consistent use of condoms will require behavior change and individual accountability. But by narrowly diagnosing AIDS as a problem of morality and by discrediting a vital component of HIV prevention, the church is advancing a remedy that is woefully inadequate. In medicine, partial therapy is at best ineffective--and at worst lethal.

If men did not stray, if women had rights, if AIDS did not kill, perhaps the church's strict ban on condom use would be morally defensible. But none of these conditions applies in Africa today. As a consequence, the cost of the church's inflexibility may mean not only untold human suffering, but the loss of millions of innocent lives.

Marcella Alsan, MD, is a physician in the Hiatt Global Health Equity Residency at Brigham and Women's Hospital, Boston.