Brian R Corbin's Reflections on Religion and Life

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Caritas: Funding Gap Sets AIDS Fight 20 Years Back
Calls on Catholic Conscience in Pandemic Battle

VIENNA, Austria, JULY 20, 2010 ( Zenit.org ).- As experts from around the world gather in Vienna to discuss the fight against AIDS, Caritas is warning that a lack of funding could put the campaign 20 years back.

The International AIDS Conference began Sunday and will run through Friday. A Catholic pre-conference networking event brought people from 23 countries together for two days previous to the AIDS conference currently underway.

At the Catholic event, Monsignor Robert Vitillo, Caritas Internationalis special representative on HIV and AIDS, spoke about the need for more funding to provide universal access to care.

It is estimated that $27 million is needed this year alone to fight the pandemic, and that a third of these costs will not be met, the agency noted.

Monsignor Vitillo reported that people are already being turned away from treatment facilities in countries such as Uganda, due to the lack of funds.

He warned that “neglecting HIV and AIDS will put millions of human lives at risk in poor countries.”

“If people don’t have access to treatment,” the priest continued, “we will return to the 1980s where there weren’t enough hospital beds and people were dying without receiving any care.”

Caritas expressed concern that children in particular will be affected by the cutbacks.

The Caritas “HAART [Highly Active Antiretroviral Therapy] for Children” campaign is calling for better testing and treatment for children with HIV and TB in poor countries. The agency noted that without this medication for children with HIV, one half of that population will die before their second birthday.

The campaign workers gathered 20,000 signatures on a petition that will be given to an Austrian government representative. Monsignor Vitillo explained that these signatures demonstrate the concern of the Austrian people for those living with AIDS in developing countries.

Catholic approach

Caritas Secretary General Lesley-Anne Knight also addressed the participants of the pre-conference Catholic networking event.

She said that “the three Cs — compassion, communion, and conscience — should underline a Catholic approach that fosters dialogue, cooperation, and an openness on how best to respond to the AIDS pandemic.”

Knight affirmed, “Our compassion needs to extend to people who are marginalized by society: to groups such as injecting drug users, men who have sex with men, commercial sex workers, and prison populations.”

“This presents us with the challenge of coming to terms with the realities of life for people within these groups,” she continued. “We need to be able to feel their suffering too and develop realistic solutions that will be effective in these diverse, difficult and complex contexts.”

“As Catholics we have much to share, but we also have an opportunity to listen and to learn,” Knight stated.

She added, “If we are to end the stigma of HIV infection and promote effective prevention strategies, we need to be able to enter into frank and honest dialogue about what are sometimes difficult issues for us to talk about.””As faith-based organizations,” Knight said, “we can appeal to the global conscience. We can promote the concept of one humanity and the idea that it is clearly wrong to do nothing while others suffer.”

She observed that “the development of a ‘global conscience’ is an important factor in putting pressure on our international institutions and governments to honor their commitments in tackling the HIV pandemic.”

Knight added, “It can also influence pharmaceutical companies to play their part in providing accessible affordable treatments.”

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Filed under: AIDS, Caritas

Searching For Solutions To AIDS

Authors Call For a Change In Strategy
By Father John Flynn, LC

ROME, JUNE 27, 2010 ( Zenit.org ).- The Catholic Church is regularly pilloried for its refusal to back the use of condoms in fighting the spread of HIV and AIDS. This nonacceptance is not only sound moral teaching, but it also has solid scientific foundations.

That’s the thesis of a book just published by the National Catholic Bioethics Center, based in Philadelphia. In “Affirming Love, Avoiding AIDS: What Africa Can Teach the West,” Matthew Hanley and Jokin de Irala take a look at why efforts to stop the spread of the HIV virus in Africa have had so little success and how this is linked to the reliance on condoms.

Hanley was the HIV/AIDS technical advisor for Catholic Relief Services until 2008 and is specialized in HIV prevention. De Irala is deputy director of the Department of Preventative Medicine and Public Health at the University of Navarra in Spain.

The authors start by noting that almost all the Western institutions active in this area share the firm opinion that risk reduction strategies, such as the promotion of condom use, must be a priority. What they term the “AIDS Establishment” has concentrated on technical means rather than on behavioral change.

The exception to this was the change in policy by the United States to adopt an ABC strategy following the success of Uganda in using this approach to deal with AIDS. The “A” stands for abstinence, “B” for be faithful, and “C” for condom use.

It’s the first two parts to this strategy that are crucial, the book argues. In fact, wherever there has been falling HIV rates in Africa, it has been the result of fundamental changes in sexual behavior.

Prevention

Seeking to modify how people behave is not only more successful but, the authors add, is a common-sense return to medicine’s principle of primary prevention. Prevention of HIV transmission is urgent in parts of the world such as Africa, where there are serious difficulties in providing adequate medical treatment.

Hanley and de Irala make a comparison with the use of tobacco. Maybe once it seemed unrealistic to change a situation where 75% of people smoked, but public health authorities embarked on campaigns to change such lifestyle choices, with success.

Why is it then, they ask, that when it comes to tobacco, cholesterol, sedentary lifestyles, and excessive consumption of alcohol, authorities consider them to be behaviors that require change, but sexual behavior associated with disease is not?

One problem associated with reliance on a risk reduction approach that looks to technical fixes instead of changes in behavior is that it can lead to what is called risk compensation. This means that the benefit obtained through the intervention of something designed to reduce risk can be offset by people becoming careless with their behavior.

The authors point out that just as a seatbelt is no guarantee of safety if someone thinks they can drive faster than normal because they are protected by it, so too condom promotion can lead to people thinking it is safe to engage in greater sexual activity.

This is particularly relevant in Africa, where studies show that when a significant number of people are engaged in concurrent sexual relationships the chances of infection are much higher compared to communities where people reduce multiple partnerships. A decline in multiple sexual partnerships is crucial to bringing about a decline in HIV rates, the authors affirm.

The best example of this was in Uganda, where HIV infection rates dropped from 15% in 1991 to 5% in 2001. What brought about this radical change was a major shift in sexual behavior, the book notes.

“This wholly rational decision to avoid the risk of a fatal and traumatic disease by altering behavior ultimately spared millions of lives,” the authors add.

Condom use

While the rate of condom use in Uganda was similar to that of Zambia, Kenya and Malawi, the number of “non-regular” partners in Uganda sharply decreased. And while the HIV rate went down in Uganda it did not decrease in the other countries.

One of the reasons behind the success in modifying conduct in Uganda, the authors point out, was the work of Catholic nuns and doctors. An Anglican bishop and a Catholic bishop were also among the first presidents of the country’s AIDS commission.

Unfortunately in recent years the AIDS establishment has gained influence in Uganda and the emphasis has shifted toward promoting the use of condoms. This has been accompanied by an increase in HIV transmission.

Kenya, Thailand and Haiti are additional countries that the authors refer to in citing evidence from studies that show how behavioral change leads to a reduction in the rates of HIV transmission.

By contrast, in South Africa, where promotion of condom use has been the main priority, the persistently high rates of multiple partnerships has helped to maintain the level of HIV infections at what the authors describe as an “alarmingly high incidence.”

The idea of abstinence does not sit easily with contemporary culture, but Hanley and de Irala point out that while fidelity appears to have been the most important factor in Africa’s success, abstinence is also important.

Abstinence influences future behavior, they maintain, and the earlier a person initiates sexual activity the more lifetime sexual partners that person is likely to have, thus increasing the risk of contracting HIV.

The book refers to a study carried out by the United States Agency for International Development which looked at variables associated with HIV prevalence in Benin, Cameroon, Keyna and Zambia.

It concluded that the only factors associated with lower HIV prevalence were lower lifetime number of partners (fidelity), an older age of sexual debut (abstinence), and male circumcision. The study also found that socio-economic status and condoms use were not associated with lower HIV prevalence.

In spite of this and other evidence provided in the book the authors point out that the documents on AIDS published by the United Nations describe the use of condoms as the most effective technology for AIDS prevention.

Condoms may well be the most effective “technology” for reducing these infections, the authors admit, but the are certainly not the most effective prevention measure.

Human sexuality

While this debate over how to deal with HIV is often cast in scientific language Hanley and de Irala maintain that it is more of a contrast between two moral and philosophical approaches to human sexuality. On one side there is the Judeo-Christian tradition, which sees sexuality as within the institution of marriage. This tradition recognized moral boundaries and the practice of self-restraint as a way to achieve human fulfillment.

On the other side is the modern Western culture that exalts absolute freedom in the pursuit of pleasure. This explains why this conceptual approach looks for technical means to deal with the undesirable consequences of sexual activity.

On June 9 Archbishop Celestino Milgiore, the permanent observer of the Holy See at the United Nations addressed the General Assembly on the issue of HIV/AIDS.

“If AIDS is to be combated by realistically facing its deeper causes and the sick are to be given the loving care they need, we need to provide people with more than knowledge, ability, technical competence and tools,” he said.

He recommended that more attention and resources be dedicated to supporting a value-based approach grounded in the human dimension of sexuality.

What we need, he continued, is an “honest evaluation of past approaches that may have been based more on ideology than on science and values, and for determined action that respects human dignity and promotes the integral development of each and every person and of all society.”

An appeal for all to cast aside prejudices and pre-conceived notions when it comes to dealing with this grave problem.

Filed under: AIDS

The Catholic Church serving people with HIV and AIDS

Please go to the following website reference to download a You-Tube video produced by Catholic Relief Services (USA) on the Catholic Church’s response to AIDS – this is the first of a series of such videos:

The Church is one of the biggest care providers for those who have HIV and AIDS around the world.

As AIDS affects every aspect of a person’s life, the Church takes a holistic approach to the disease, focusing on the physical, intellectual and spiritual needs of the person.

Up to 33 million people were living with HIV in 2007. It is a disease which is particularly prevalent in Sub-Saharan Africa, where countries are often poor and services are not always available.

The Church has unprecedented access to people with HIV and AIDS across the world and on a grassroots level. It has a global network of schools, churches, orphanages, hospices, organisations such as Caritas plus an army of faithful who offer their services.

Besides healthcare, it gives counseling to people who have been affected by the illness and offers spiritual guidance to help them face what is possibly one of the toughest challenges of their lives. It also provides the nutritious food which is vital in ensuring antiretroviral treatment is successful.

Other areas the Church works in include educating and informing people about the risk of AIDS and how to prevent it. The Church also focuses its efforts on reducing the stigma and discrimination which often accompanies HIV and AIDS.

Advocacy is a big part of its work. For example, Caritas Internationalis is currently urging governments and pharmaceutical firms to produce child-friendly HIV and AIDS medicines and to improve testing, as many children currently die due to lack of medicines.

All in all, the Church works hard to help people with HIV and AIDS live in hope and, when the time comes, die with dignity.

Filed under: AIDS, Caritas, Catholic Relief Services

The Pope May Be Right: Condom/HIV discussion continues

By Edward C. Green

Sunday, March 29, 2009; Page A15

When Pope Benedict XVI commented this month that condom distribution isn’t helping, and may be worsening, the spread of HIV/AIDS in Africa, he set off a firestorm of protest. Most non-Catholic commentary has been highly critical of the pope. A cartoon in the Philadelphia Inquirer, reprinted in The Post, showed the pope somewhat ghoulishly praising a throng of sick and dying Africans: “Blessed are the sick, for they have not used condoms.”

Yet, in truth, current empirical evidence supports him.

We liberals who work in the fields of global HIV/AIDS and family planning take terrible professional risks if we side with the pope on a divisive topic such as this. The condom has become a symbol of freedom and — along with contraception — female emancipation, so those who question condom orthodoxy are accused of being against these causes. My comments are only about the question of condoms working to stem the spread of AIDS in Africa’s generalized epidemics — nowhere else.

In 2003, Norman Hearst and Sanny Chen of the University of California conducted a condom effectiveness study for the United Nations’ AIDS program and found no evidence of condoms working as a primary in HIV-prevention measure in Africa. UNAIDS quietly disowned the study. (The authors eventually managed to publish their findings in the quarterly Studies in Family Planning.) Since then, major articles in other peer-reviewed journals such as the Lancet, Science and BMJ have confirmed that condoms have not worked as a primary intervention in the population-wide epidemics of Africa. In a 2008 article in Science called ” Reassessing HIV Prevention ” 10 AIDS experts concluded that “consistent condom use has not reached a sufficiently high level, even after many years of widespread and often aggressive promotion, to produce a measurable slowing of new infections in the generalized epidemics of Sub-Saharan Africa.”

Let me quickly add that condom promotion has worked in countries such as Thailand and Cambodia, where most HIV is transmitted through commercial sex and where it has been possible to enforce a 100 percent condom use policy in brothels (but not outside of them). In theory, condom promotions ought to work everywhere. And intuitively, some condom use ought to be better than no use. But that’s not what the research in Africa shows.

Why not?

One reason is “risk compensation.” That is, when people think they’re made safe by using condoms at least some of the time, they actually engage in riskier sex.

Another factor is that people seldom use condoms in steady relationships because doing so would imply a lack of trust. (And if condom use rates go up, it’s possible we are seeing an increase of casual or commercial sex.) However, it’s those ongoing relationships that drive Africa’s worst epidemics. In these, most HIV infections are found in general populations, not in high-risk groups such as sex workers, gay men or persons who inject drugs. And in significant proportions of African populations, people have two or more regular sex partners who overlap in time. In Botswana, which has one of the world’s highest HIV rates, 43 percent of men and 17 percent of women surveyed had two or more regular sex partners in the previous year.

These ongoing multiple concurrent sex partnerships resemble a giant, invisible web of relationships through which HIV/AIDS spreads. A study in Malawi showed that even though the average number of sexual partners was only slightly over two, fully two-thirds of this population was interconnected through such networks of overlapping, ongoing relationships.

So what has worked in Africa? Strategies that break up these multiple and concurrent sexual networks — or, in plain language, faithful mutual monogamy or at least reduction in numbers of partners, especially concurrent ones. “Closed” or faithful polygamy can work as well.

In Uganda’s early, largely home-grown AIDS program, which began in 1986, the focus was on “Sticking to One Partner” or “Zero Grazing” (which meant remaining faithful within a polygamous marriage) and “Loving Faithfully.” These simple messages worked. More recently, the two countries with the highest HIV infection rates, Swaziland and Botswana, have both launched campaigns that discourage people from having multiple and concurrent sexual partners.

Don’t misunderstand me; I am not anti-condom. All people should have full access to condoms, and condoms should always be a backup strategy for those who will not or cannot remain in a mutually faithful relationship. This was a key point in a 2004 “consensus statement” published and endorsed by some 150 global AIDS experts, including representatives the United Nations, World Health Organization and World Bank. These experts also affirmed that for sexually active adults, the first priority should be to promote mutual fidelity. Moreover, liberals and conservatives agree that condoms cannot address challenges that remain critical in Africa such as cross-generational sex, gender inequality and an end to domestic violence, rape and sexual coercion.

Surely it’s time to start providing more evidence-based AIDS prevention in Africa.

The writer is a senior research scientist at the Harvard School of Public Health

Filed under: AIDS, Personal Reflections, Politics

Leading HIV researcher Edward C. Green says criticism of the pope ‘unfair.’ Comments?

An interview of Edward (Ted) Green at Harvard by Christianity Today:

 Interview Condoms, HIV, and Pope Benedict

 

Interview by Timothy C. Morgan | posted 3/20/2009 04:27PM

E dward C. Green is one of the world’s leading field researchers on the spread of HIV and public health interventions. He’s the director of the Harvard AIDS Prevention Research Project, and is a leading advocate for evidence-based interventions. He has been sharply criticized by some public health experts for supporting sexual partner reduction programs and for endorsing the so-called ABC method (“Abstain, Be faithful, or use a Condom”) for fighting the transmission of HIV.

After Pope Benedict’s comments earlier this week, Green agreed to answer Christianity Today deputy managing editor Tim Morgan’s questions by e-mail.

Is Pope Benedict being criticized unfairly for his comments about HIV and condoms?

This is hard for a liberal like me to admit, but yes, it’s unfair because in fact, the best evidence we have supports his comments — at least his major comments, the ones I have seen.

What does the evidence show about the effectiveness of condom-use strategies in reducing HIV infection rates among large-scale populations?

It will be easiest if we confine our discussion to Africa, because that’s where the pope is, and that is what he was talking about. There’s no evidence at all that condoms have worked as a public health intervention intended to reduce HIV infections at the “level of population.” This is a bit difficult to understand. It may well make sense for an individual to use condoms every time, or as often as possible, and he may well decrease his chances of catching HIV. But we are talking about programs, large efforts that either work or fail at the level of countries, or, as we say in public health, the level of population. Major articles published in Science , The Lancet , British Medical Journal , and even Studies in Family Planning have reported this finding since 2004. I first wrote about putting emphasis on fidelity instead of condoms in Africa in 1988.

Is there any country worldwide (Brazil or Thailand, for example) that has emphasized condoms where a reduction in HIV infections has been verified and sustained?

In countries where HIV is largely concentrated among prostitutes and their clients, such as Thailand and Cambodia, there seems to have been success in promoting the so-called 100 percent condom policy in brothels. Most analysts credit the decline of HIV infection rates there to this policy and its implementation (of course, they were saying that about Uganda as well), but I agree that this probably has been the major factor explaining prevalence decline in those two countries. However, condom use is not especially high for prostitutes and their clients who are not based in brothels. And another factor in both countries is surely that there was a significant decline in the proportion of men going to prostitutes of any sort, and there was even a big decline in the proportion of men having extramarital sex in the years before we first saw infections decrease in Thailand.

Is there any country in Africa with a high HIV infection rate that has implemented new programs and seen infection rates fall? If so, what strategies are being followed?

I’m glad you asked this. We are seeing HIV decline in eight or nine African countries. In every case, there’s been a decrease in the proportion of men and women reporting multiple sexual partners. Ironically, in the first country where we saw this, Uganda, HIV prevalence decline stopped in about 2004, and infection rates appear to be rising again. This appears to be in part because emphasis on interventions that promote monogamy and fidelity has weakened significantly, and earlier behavior changes have eroded. There has been a steady increase in the very behavior that once accounted for rates declining — namely, having multiple and concurrent sex partners. There is a widespread belief that somehow Uganda had fewer condoms. In fact, foreign donors have persuaded Uganda to put even more emphasis on condoms.

What about Swaziland, which has a reputation for one of the highest HIV rates in the world? Do condoms work there? If not, what would?

As I have said, condoms have not worked in any country in Africa. The two countries with the highest infection rates, Swaziland and Botswana, have both launched MCP campaigns. “MCP” is shorthand for campaigns that discourage people from having multiple and concurrent sexual partners. We are starting to see prevalence decline in both of these countries.

Is the African church part of the problem here for creating a stigma and demonizing people with HIV?

That charge has been way overblown. There was some of that early in the pandemic, but the churches’ involvement and intervention are essential. For one thing, they have always been right about where to put the emphasis — namely, on marital fidelity and abstinence, or delay of the age of first sex. All faith-based organizations promote this, whatever the denomination or religion. Faith-based organizations are some of the most powerful NGOs in Africa, and they play a leading role not only in general health and education in these countries, but also in caring for the sick and dying in the AIDS epidemics we find in Africa, from the very beginning. I think historians will look back and find great fault in the fact that the major AIDS donor organizations did really not bring the religious groups into prevention activities at or near the beginning of the pandemic.

What is the best HIV prevention strategy for the Obama administration to fund with new PEPFAR money?

Well, my views here also upset a lot of my colleagues, but I’ve always said that we cannot treat our way out of this pandemic. A sound public health approach is always based on good prevention strategies. We can justify treatment with expensive anti-retroviral drugs on humanitarian grounds, but it’s hard to do on public health grounds. So I would advise Obama, the candidate I voted for, to put more emphasis on prevention, and to face up to the hard realities of the best evidence available to date, which shows that condom promotion, testing and counseling, curing the curable STDs, or any of the other interventions widely endorsed and considered “best practices” always funded have simply not worked in Africa. (It’s possible they may work in other regions, like condoms in Thailand, so it’s easy for me to be misquoted on something like this.) In a number of studies, these interventions have actually been shown to not work. The two interventions that work best in Africa are promotion of monogamy and fidelity, and male circumcision. We have even stronger science behind the latter. I assume people know about “the male circumcision factor” these days, so I will not say more here.

As for IDU (injecting drug use) epidemics, I would advise putting resources into preventing addiction in the first place and into treatment of drug addicts and facilitation of support groups to keep addicts from relapsing, groups like those following the 12-steps.

Filed under: AIDS