AIDS in Africa: Abstinence Works
Interview With Expert Matthew Hanley
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BALTIMORE, Maryland, FEB. 27, 2008 (Zenit.org).- In the fight against AIDS, abstinence-based programs that focus on changing behaviors rather than handing out condoms simply work better, says an AIDS expert.
Matthew Hanley has been a HIV/AIDS technical adviser at Catholic Relief Services (CRS) for the last seven years and is the author of the forthcoming book "Avoiding Risk, Affirming Life: Science, Love, and AIDS."
In this interview with ZENIT, Hanley comments on the programs and principles that have led to dropping rates of HIV prevalence in Africa.
Q: You seem to be something of a lone voice in the wilderness promoting Catholic principles in the fight against AIDS, and yet so much of the research is showing that this approach is really what is heading off the disease. How and where is this actually working?
Hanley: First, actual changes in patterns of sexual behavior have led to the most significant reductions in HIV prevalence. Take the well-known case of Uganda, where the prevalence rate dropped from 15% in 1991 to a little over 5% in 2001. Behavior change was so thorough in Uganda that by the mid-1990s, 95% of adults in that country said they had only one partner or none at all. But it is not only Uganda.
The most important factor in recent HIV declines observed in several other countries, such as Kenya, Zimbabwe and Haiti has been an increase in fidelity or "partner reduction." This should not be altogether surprising, considering that in a large swath of southern Africa, where over half of new infections globally come from, the AIDS epidemic is being driven by the dynamics of multiple and often concurrent sexual partnerships.
Where this kind of behavior change has not taken place, HIV incidence has remained high. This is the case in South Africa, which has been a vigorous promoter of condoms, but rather silent about the need for a more profound modification of behavior, specifically multiple partnerships.
The primacy of behavior change comes into even sharper relief when we consider that the two other major planks of HIV prevention besides condoms -- treating other sexually transmitted infections, and the promotion of voluntary counseling and testing -- have not been particularly effective in decreasing HIV incidence.
Q: One currently popular approach to AIDS prevention is called ABC -- Abstinence, Be Faithful, Condoms. The Catholic Church supports the AB. As someone who works in the fight against AIDS in a Catholic organization, how do you present the Church's teaching against condom use?
Hanley: First, we try to articulate what the Church actually proposes, abstinence and fidelity, in a positive manner. I have found in my trips to Africa that there is a real thirst for something different, something hopeful. We all know that people yearn for more than the satisfaction of their appetites. In other words, they yearn for love, for respect and for meaning in life. In his first encyclical, "Deus Caritas Est," Benedict XVI reminded us of long-standing Christian tradition, namely that human beings are a "union of body and soul," that love is characterized by exclusivity, or fidelity, and that love contains a quality of permanence over time.
When we conducted training recently with five dioceses in Ethiopia, one of the participants, a wife and a mother, spoke for the group by saying how much she appreciated the emphasis on fidelity and related human values such as respect and communication. She was puzzled as to why such basic themes are not more routinely promoted in the context of HIV prevention, adding: "Why hasn't anyone explained it like this before?"
So we try to address the whole human person, their deeper aspirations, and in proposing love, affirm basic Christian sexual ethics. It is on this level that the Church then encounters the wider culture, which as Pope John Paul II suggested in "Familiaris Consortio," often holds "fundamentally irreconcilable views of the human person and of human sexuality," leading many to aggressively reject these first principles.
Perhaps one of the most helpful means that I have seen of expressing the moral significance of the issues involved comes from the Kenyan bishops. In their pastoral letter on AIDS, they hit upon the crux of the matter: The Church proposes the same sexual morality even "when and where AIDS poses no danger." The central issue with respect to the Church's consistent teaching on sexual matters is thus not the risk of HIV, but the lack of chastity, and "this is not easy for 'the world' to grasp."
So the Catholic Church, among others, objects to the widespread promotion of condoms, primarily on legitimate moral and ethical grounds, over and above the practical limitations observed to date in practice.
I think it is also fair to point out that even from a practical point of view, the claims made by religious leaders -- that the promotion of condom use could lead to a false sense of security and even end up increasing overall risk -- have been echoed in the scientific literature; even long-time condom advocates have described this phenomenon as real.
Q: From your experience, why is there so much pressure to promote the C of the ABC approach given that despite the moral implications, it is not proving to be effective?
Hanley: Yes, researchers have noted that in many countries in sub-Saharan Africa, HIV transmission rates have remained high despite a considerable increase in condom use. For example, condom sales in Botswana increased from 1 million in 1993 to 3 million in 2001, while HIV prevalence among pregnant urban women increased from 27% to 45%. In Cameroon, during the same period, condom sales rose from 6 million to 15 million, while HIV prevalence increased from 3% to 9%.
A study commissioned by UNAIDS concluded, "Prevention campaigns relying primarily on the use of condoms have not been responsible for turning around any generalized epidemic."
I also found one survey conducted in Lesotho to be particularly revealing. It found that about 75% of respondents could identify condoms as a means of preventing HIV, but only approximately 5% of respondents identified abstinence or faithfulness as a means of avoiding HIV.
The more interesting element to consider, implicit in your question, is the underlying assumptions and philosophy behind how prevention measures are prioritized and emphasized. Since the primary approach of condoms, voluntary counseling and testing and treatment of other sexually transmitted infections, has not produced the intended results, in terms of achieving reductions in HIV prevalence, it would be difficult to avoid concluding that these interventions maintain their privileged position not because of empirically observed scientific excellence, but at least in part because of the desire of their proponents to cling to an underlying vision of the human person, freedom and sexuality.
Yet it is the Church that is routinely characterized as being opposed to science, or "dogmatic." But this charge does not stand up to scrutiny. The reference to dogma, though, calls to mind one of G.K. Chesterton's observations, "There are two kinds of people: Those who have a dogma and know it, and those who have a dogma and don't know it."
In other words, any approach to these issues is inherently charged with meaning. As products of our own time and place, we all naturally bring some sort of vision to the table, some presuppositions about life, relationships, sexuality, the dignity of the human person, family and so many other fundamental topics.
Beyond that, public health is deeply influenced by a kind of utilitarianism, known for its aim to achieve the "greatest happiness for the largest number." As it applies to HIV prevention policy, the objective becomes seeking to maximize the good of sexual pleasure while minimizing the pain of AIDS. But as the very name suggests, utilitarianism allows for the use or the manipulation of one person by another. In Christian thought, to "use" another person is the polar opposite of loving another person.
Public health approaches also borrow heavily from an inflated sense of "human autonomy" within the wider culture. This form of individualism exalts personal freedom as the supreme value. Freedom is thus enthroned above truth, as opposed to being subject to it. It is a concept of freedom that is, rather sadly, unencumbered by human relationships.
These schools of thought, in denying and rejecting objective moral and philosophical truths, advance no internally consistent or coherent rationale for limiting sexual partnerships, and thus tend to yield interventions that would rightly only be considered "secondary" measures of HIV prevention.