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Working with people living with HIV/AIDS organizations:

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Chapter 1 Introduction

This document has been written to accompany World Council of Churches, Partnerships between Churches and People Living with HIV/AIDS Organizations: Guidelines, (2005). Whereas the partnership document explores the question of why churches should work with People Living with HIV/AIDS (PLWHA) organizations and networks, this document has a focus on how churches may work with PLWHA organizations and networks. For example: What issues do you need to think about? What are the needs of PLWHA? How should you interact PLWHA? It is hoped that this document of practical suggestions will assist in helping make partnerships functional and effective.

Chapters two and three look at some of the issues which confront churches and PLWHA organizations in their attempts to forge partnerships. Essentially this is an appraisal of the point churches and PLWHA organizations are at now. Many of the issues described are testing the compassion and HIV and AIDS competency of churches and often there are no easy answers. For examples, issues such as HIV prevention, including prevention inside marriage and abstinence before marriage, and human sexuality, including same-sex relations, have the potential to divide churches and to create obstacles to partnerships with PLWHA and between faiths. Even if some positions are contentious or unpopular, churches need to be able to articulate their positions logically and coherently.

Similarly, PLWHA organizations are also faced with an array of issues some of which may be divisive such as how to respond to PLWHA who knowingly put others at risk of exposure to HIV; HIV-positive husbands and partners who force themselves on their wives or partners; and in some regions, inter-generational sex as a perceived method of curing HIV infection.

Acknowledging these difficulties and working towards a common understanding with partners, is one step in defusing the divisive nature of some of these challenges and perhaps finding solutions. Defining boundaries means that both parties can see what is possible and what is not; thereby creating clarity when making decisions.

While chapters two and three provide background on churches and PLWHA organizations, chapter four is the heart of the document. Chapter 4 provides concrete information on an array of issues which may need to be addressed in working with PLWHA organizations. Particularly note worthy are the sections on confidentiality, tokenism, capacity building, and monitoring and evaluation. A recurrent theme is the role of churches in advocating for access to treatment, including anti-retroviral therapy.

Boxes are used throughout the text to highlight specific issues or to provide examples of projects or programmes or partnerships that have been successful. The illustrative material in this document comes from a number of existing studies and reports. One of the benefits of increased cooperation and the development of partnerships between churches and PLWHA organizations will be a growing body of knowledge of how to work together and work through periods of uncertainty, discontent and perhaps even confrontation. This will strengthen the partners involved as well as churches and PLWHA organizations generally.

The Annexes contain sections on a self assessment framework for AIDS competence, the correct use of HIV- and AIDS-related language, the Covenant Document on HIV/AIDS and human capacity development.

Please note that the full texts of the declarations by churches on HIV listed in Box one ?List of Declarations and Policy Statements by Churches and Faith-based Organizations from 2001 to 2004? are available on the World Council of Churches website at http://www.ecuspace.net/contact.nsf. If you do not have access to internet; you can obtain copies from:
Manoj Kurian
Dr. Manoj Kurian
Programme Executive, Health and Healing Mission Team
World Council of Churches
Box 2100
1211 Geneva, Switzerland
Tel: +41 22 791 63 23
Fax: +41 22 791 61 22
mku@wcc-coe.org

Chapter 2: Looking inside …

This chapter looks at some of the issues which confront churches and PLWHA organizations in their attempts to forge partnerships.

The section on churches acknowledges the transition that has occurred in many churches but questions whether words have been translated into actions. The section also highlights the practical difficulties that can occur in involving PLWHA and different strategies or initiatives to eradicate HIV-related stigma.

With regards to PLWHA organizations, the section highlights the diversity of people captured under the term “PLWHA” and charts the history of the PLWHA movement both before and after the formulation of the Greater Involvement of PLWHA (GIPA) Principle at the Paris Conference, 1 December 1994. It also highlights some of the taboo subjects in relation to PLWHA and suggests that partnerships with churches will enable a dialogue to find solutions to these difficult subjects.

2.1 Looking inside your church

Covenant 8: Church, PLWHA and HIV/AIDS 1

We shall remember, proclaim and act on the fact that we are one body of Christ and if one member suffers, we all suffer together with it; that the Lord our God identifies with the suffering and marginalized and heals the sick (1 Corinthians. 14:26; Matthew 25:31–46). We shall, therefore, become a community of compassion and healing, a safe place for all PLWHA to live openly and productively with their status.

As many good ideas can suffer face insurmountable obstacles if people begin on the wrong foot, both churches and PLWHA organizations need to be prepared to work together before commencing the common journey of a partnership. Many PLWHA have been stigmatized in their communities and discriminated against institutionally sometimes by churches. The perceptions that churches condemn sinners and promote very narrow guidelines on HIV prevention have created negative popular views in many people in some regions of the world of churches and their response to HIV. There is a need for reconciliation for the individual, but also between individuals, and between individuals and their churches. For this to be possible churches and PLWHA need to be able to listen and be open, humble, forgiving and most of all capable of showing true love.

A climate of denial regarding HIV and AIDS issues has affected, and in some cases continues to affect, some churches and faith-based organizations. For example, the Siyam’kela study, South Africa found that this was especially the case in more middle-class Christian congregations, as well as the Muslim-faith community, which did not believe that HIV and AIDS was a problem in their communities. 2

As was outlined in the introduction of the accompanying document World Council of Churches, Partnerships between Churches and People Living with HIV/AIDS Organizations: Guidelines (2005) churches are in many different places in responding to HIV; some are still in denial. While many churches and faith-based organizations have begun the proverbial trek across the Red Sea or are struggling in the wilderness. AIDS raises many issues for churches – some of which have previously been taboo or extremely difficult to confront, for example, from sexual abuse and violence, rape, incest and infidelity, drug use as well as death and dying to accepting the innate sexuality of every human being. As discussed in chapter three, churches are faced with an array of issues around HIV prevention, sin and sexuality. In some respects, it is not surprising that twenty years into a global pandemic, churches are still struggling with how to respond.

Many churches have implemented a wide range of interventions, mainly focusing on interventions and programmes to provide care and support to PLWHA – traditional responses by churches. Faith-based organizations have responded to the specific needs of PLWHA in terms of material support such as nutritional programmes and the distribution of food parcels, setting up support groups for faith community members who were living with and affected by HIV and AIDS, as well as pastoral care. Churches have also formed support groups and prayer groups.

Where possible, faith-based organizations have attempted to respond to the health care needs of PLWHA in the form of home-based care or establishing hospices in the community. The provision of antiretroviral therapy is also becoming a reality. The Pontifical Council for Health Pastoral Care estimates that 26.7% of the centres dedicated to treating HIV/AIDS in the world are Catholic centres 3. However, such work is dependant on the funding and having relevant trained personnel 4.

Religious leaders can be sensitive to the needs of PLWHA and are beginning to play a major role in promoting a culture of acceptance and respect for PLWHA, including notions of responsibility and tolerance 5. Provision of spiritual and moral care to those living with and affected by HIV and AIDS is often needed because people may experience a range of difficult emotions, including fear of death, depression, suicidal ideation, guilt, anguish, anger, denial, shock, rejection and isolation arising from stigmatization6. Thus, for example, one faith leader in the Siyam’kela study, South Africa, suggested that the church could facilitate the emotional healing of a person who has learnt that they are HIV-positive by providing a ‘humane and loving’ environment through, for example, pastoral counselling and prayers 7.

Given the newness of HIV and AIDS as a serious endeavour for churches and/or congregations, some churches like many governments and other organizations, made mistakes in their initial response, which contributed to HIV-related stigma and discrimination. In 2001 Canon Gideon Byamughisha pointed out that, It is now common knowledge that in HIV/AIDS, it is not the condition itself that hurts most (because many other diseases and conditions lead to serious suffering and death) but the stigma and the possibility of rejection and discrimination and loss of trust that HIV-positive people have to deal with 8. Some churches and individuals still stigmatize HIV and discriminate against PLWHA; however, overwhelmingly churches have made, and are making, great efforts towards breaking the stigma both within their church and in society more generally. The extent of such change is extremely variable across regions, and between and within churches. There can also be different reactions between church leadership and church members. Sometimes leaders are moving faster than their flock and sometimes a stubborn bishop stops his members from acting in a Christian way. As an example of the variability of responses, see the reactions described in box two “Jamaica Council of Churches drafting policy on HIV/AIDS” below.

From 2001 onwards there have been a series of declarations and policy statements from various churches’ governance bodies. The most significant ones are listed in the box one.

Box 1: List of Declarations and Policy Statements by churches and faith-based organizations from 2001 to 2004 9

2001
All Africa Conference of Churches, Mukono - Kampala Declaration. Mukono - Kampala, Uganda, 15–17 January 2001.

Church of Norway, Statement from the Bishops’ Conference. April 2001

All Africa Conference of Churches, The Dakar Declaration. Dakar, Senegal, 23–25 April 2001.

Southern African Bishops Conference. A Message of Hope to the People of God from the Catholic Bishops of South Africa, Botswana, and Swaziland. Pretoria, South Africa, 30 July 2001.

Anglican Communion across Africa. All Africa Anglican AIDS Planning Framework "Our Vision, Our Hope" The First Step. Johannesburg, South Africa, 22 August 2001.

The Ecumenical Response to HIV/AIDS in Africa (EHAIA). Plan of Action, Global Consultation on Ecumenical Responses to the Challenges of HIV/AIDS in Africa. Nairobi, Kenya, 25–28 November 2001

Christian Conference of Asia, Consultation on HIV/AIDS: A challenge for religious response: Statement. Chiang Mai, Thailand, 25–30 November 2001.

2002
The Lutheran World Federation, Compassion, Conversion, Care: Responding as churches to the HIV/AIDS pandemic. An Action Plan of the Lutheran World Federation, 18 January 2002.

Anglican Primates, Report of the Meeting of Primates of the Anglican Communion: Appendix III Statement of Anglican Primates on HIV/AIDS, Canterbury, United Kingdom, 17 April 2002.

Pan-African Lutheran Church Leadership, Breaking the Silence, Commitments of the Pan-African Lutheran Church Leadership Consultation in response to the HIV/AIDS pandemic. Nairobi, Kenya, 2–6 May 2002

World Council of Churches (WCC) and Christian Conference of Asia (CCA). Report of the WCC-CCA Consultation on ‘An Ecumenical Agenda to combat HIV/AIDS in South Asia’. Colombo, Sri Lanka, 24–26 July 2002.

Council of Anglican Provinces in Africa (CAPA). Statement from CAPA AIDS Board Meeting. Nairobi, Kenya, 19–22 August 2002.

World YWCA. Executive Committee. Geneva, Switzerland, November 2002

World YWCA. Executive Committee: HIV/AIDS Policy. Geneva, Switzerland, November 2002

2003
Lutheran World Federation, Latin America Regional Consultation on the Lutheran World Federation Plan of Action, “Compassion, Conversion, Care” - Justice, conversion and integration, Catia la Mar, Venezuela, March 2003.

Primates of the Anglican Communion. Pastoral letter from the Primates of the Anglican Communion. 27 May 2003.

Council for World Mission. Assembly Statement. Ayr, Scotland, 15–25 June 2003

Lutheran World Federation, Adopted version of message from the Tenth Assembly, Winnipeg, Canada, 21–31 July 2003.

World YWCA. World Council Resolution: Reproductive Health and Sexuality. Brisbane, Australia, July 2003.

Norwegian Church Aid. HIV/AIDS, A policy statement from Norwegian Church Aid. Approved by NCA Board 29 September 2003.

Symposium of Episcopal Conferences of Africa and Madagascar, The Church in Africa in face of HIV/AIDS Pandemic, Message issued by Symposium of Episcopal Conferences of Africa and Madagascar (SECAM), Dakar, Senegal, 7 October 2003.

East - Central Africa Division of Seventh-day Adventist Church. East - Central Africa Division (ECD) of Seventh-day Adventist (SDA) Church Regional Workshop on HIV/AIDS. The Nairobi Declaration. Nairobi Kenya, 10–13 November 2003.

Church of Nigeria (Anglican Communion). Communiqué, National HIV/AIDS Strategic planning and policy development workshop. Abuja, Nigeria, 10–14 November 2003.

Interfaith: Christian Conference of Asia, World Council of Churches, Christian Aid, Norwegian Church Aid, United Evangelical Mission, Church of Christ in Thailand AIDS Ministry and Ecumenical Coalition on Tourism, For we are Neighbours: Statement from the Interfaith AIDS Conference, Bangkok, Thailand, 20–25 November 2003.

Catholic Bishops of Myanmar. Pastoral Letter on HIV/AIDS and the Response of the Church. December 2003

Indian Catholic Bishops. Pastoral Letter from Indian Bishops for World AIDS Day 2003: The challenge to be his Light today.1 December 2003.

Lutheran World Federation and the United Evangelical Mission, "Covenant of life"- Statement of Commitment of the Asian Church Leadership Consultation on HIV/AIDS, Batam Island, Indonesia, 1–4 December 2003.

Memorandum of Intention, Strategy consultation on Churches and HIV/AIDS in central and eastern Europe. St. Petersburg, Russia, 15–18 December 2003.

2004
Romanian Orthodox Church. His Beatitude Teoctist, Patriarch of the Romanian Orthodox Church. A message, urging to love and tolerance for those suffering from AIDS/HIV. Romania, 27 January 2004.

Regional Meeting facilitated by the Latin American Council of Churches (CLAI) and supported by the World Council of Churches (WCC), The Church and HIV/AIDS in Latin America and the Caribbean, Panama City, Panama, 27 January–1 February 2004.

World YWCA. YMCA Global Capacity Building Forum on HIV/AIDS: Strategic Framework for a Global YMCA Action Plan on HIV/AIDS. Durban, South Africa. March 2004.

World YMCA. YMCA Global Capacity Building Forum on HIV/AIDS: YMCA Movement Statement on HIV/AIDS. Durban, South Africa. March 2004.

World Council of Churches’ Pacific Member Churches, The Nadi Declaration: A statement of the world council of churches’ Pacific Member Churches on HIV/AIDS. Nadi, Fuji, 29 March–1 April 2004.

World YMCA. Recommendations on HIV/AIDS adopted by the World Alliance Executive Committee. Hong Kong, 2 April 2004.

The United Methodist Church. Global AIDS Fund Resolution – Adopted by 2004 General Conference. Pennsylvania, United States, 27 April–7 May 2004

The United Methodist Church. Drugs and AIDS Resolution – Adopted by 2004 General Conference. Pennsylvania, United States, 27 April–7 May 2004

Asian Muslim Action Network, Asian Resource Foundation and Thai Muslim Network. International Pre-conference Muslim Workshop on HIV/AIDS. In the name of Allah, the Beneficent, the Merciful. Bangkok, Thailand, 9 July 2004.

Provincial Anglican Bishop. Communique, The Province of Central Africa Bishops Retreat, Malawi, 13–14 July, 2004.

United Evangelical Mission, Anti HIV/Aids Programme Policy, Adopted by the UEM General Assembly in Manila, October 2004.

Latin America, Message from Churches, Organizations and Programmes on World AIDS Day 2004, Women, Girls and HIV/AIDS. 1 December 2004.

Interfaith. International Interfaith Conference on Prevention and Control of HIV/AIDS, Delhi Declaration. Delhi, India, 1–2 December 2004

The Cairo Declaration of Religious Leaders in the Arab States in Response to the HIV/AIDS Epidemic. Cairo, Egypt, 11–13 December 2004.

In the history of HIV and AIDS there have been literally hundreds of declarations made by PLWHA organizations locally, nationally and internationally, by nongovernmental organizations (NGOs), the UN and governments, few of which have been put into effect. Declarations can be ways of directing the attention of a church to an issue. The question for churches, who want to be seen as credible and accountable, is whether all the time, energy and money expended in gathering leaders together and formulating declarations really leads to concrete coherent actions in countries and parishes, which in turn have measurable effects on the lives of people.

Most declarations highlight that churches and church and ecumenical organizations are grappling with the HIV- and AIDS-related stigma. An effective way of moving from declarations to implementation of intentions is to find concrete and sustainable ways of working with PLWHA and their organizations. This can form an indicator for monitoring and evaluating the partnership.

Discuss

Is your parish or church updated on declarations made by its leaders?
What has been done in your parish to implement the points in the declaration made by your church?
Who in your parish or church is responsible for following up on the implementation of the commitments made in the declaration?

The example offered below in box two “Jamaica Council of Churches drafting policy on HIV/AIDS” illustrates how churches in Jamaica and in the wider Caribbean are responding and highlights the difficulties in countering HIV-related stigma.

Box 2: Jamaica Council of Churches drafting policy on HIV/AIDS 10

Several church leaders admitted that their biggest obstacle to getting an HIV/AIDS outreach going in their community was the stigma and discrimination against persons infected with the disease. They (churches) are not getting a favourable response from the community, programmes officer for the Jamaica Council of Churches (JCC) HIV/AIDS project, Ainsley Reid, said. People (clergy) are excited and willing to do something, but in rural Jamaica there is a big challenge because of the stigma that exists at the level of the community.

He said that pastors and lay leaders participating in a workshop in St James had their own 'misconceptions' about the disease and how it is contracted. The December 2004 workshop was the second of four being hosted by the Jamaica Council of Churches to sensitise more than 140 clergy and lay leaders island wide about HIV.

The JCC's work is part of a bigger project which started in June 2003, involving a number of inter-religious organizations in 13 other CARICOM territories. The project, called "Building a Faith-Based Response to HIV/AIDS in the Caribbean", is being spearheaded by the Caribbean Council of Churches with a Canadian$ 2 million grant from the Canadian Development Agency (CIDA). A major component is the formulation of a set of guidelines that will guide churches in the region in developing their own intervention strategies.

An inter-religious HIV/AIDS policy committee, convened by the CCC in May this year, is now preparing a document outlining "Guidelines for Caribbean Faith-Based organizations in Developing Policies and Action Plans to Deal with HIV/AIDS".

Many different strategies are required to counter stigma. Box three “Strategies for Hope Trust: What can I do?” describes a new video, designed to combat HIV-related stigma, shame, discrimination and denial in churches. The video features Rev. Canon Gideon Byamugisha from Uganda – one of the first African priest to disclose his HIV-positive status. For more information on Rev Gideon, see box 20 “Canon Gideon Byamugisha – the Anglican Church stands behind its pastors” in 4.3 Confidentiality.

Reducing stigma involves a wide variety of activities, many which churches and faith-based organizations are already involved in. Box four on the “Church of the Province of Southern Africa HIV programme” highlights this – the goal is to be achieved through the sum of all the component activities.

Box 4: Church of the Province of Southern Africa HIV programme, 2003–2006 11

The Christian Aid supported CPSA programme is ambitions and complex – attempting to challenge stigma and discrimination within the church and wider community and support a wide variety of HIV care and prevention programmes. Although churches in Africa often have relatively conservative views and have sometimes been instrumental in promoting stigma and negative attitudes to PHWLA this programme aims to counteract these views. In the 6 countries (and 26 dioceses) in which it works there are a wider range of approaches with some dioceses having more active involvement of PHWLA and have more developed programmes. The challenge is to support all dioceses to develop and expand their work, and working with the African Network of Religious Leaders Living with or personally affected by HIV/AIDS (ANERELA+) is seen as key to this.

As of June 2004, the programme had recruited and trained CPSA HIV staff and set up an HIV office to manage the programme. Twenty-three dioceses in six countries had been supported in their HIV work and helped to access other sources of funding. In addition, they were assisted in strengthening ecumenical and interfaith dialogue and collaboration. Training was given to clergy and lay leadership, and was assisted closely by ANERELA+. CPSA has now embarked on a program to actively support and encourage members living with HIV into fuller involvement in the program, starting with a residential retreat planned for later in 2005, in which ANERELA will be playing a leading role.

Workplace programmes and policies are being developed to protect the rights of church workers, clergy and lay leaders living with HIV and AIDS. Information on access to social grants has been developed, and linkages have been established with other churches and faith-based and community organizations.

See “From Boksburg to Canterbury - Steps to Putting HIV/AIDS on the Anglican Map” http://www.anglicancommunion.org/special/hivaids/

Even though many faith-based structures are now beginning to realize the importance of encouraging openness and realism in responding to HIV and AIDS; religious communities still have a long way to go, especially when it comes to actually understanding how to communicate about HIV and AIDS in all aspects of their work. It is not sufficient to set up a network or a self-help group of PLWHA; if the religious community continues to stigmatize in other areas. Norwegian Church Aid (NCA) experienced a striking example of such a situation as described in box five below.

Box 5: Destigmatizing HIV within a church – internal communications 12

Norwegian Church Aid (NCA) supported a large faith-based organization, working in a very poor urban area, to set up a self-help group for PLWHA. The group met regularly once a week at the church campus. As stigma and discrimination was a serious problem in this area, the group soon became very popular and was appreciated by PLWHA as a “refuge”, a place for receiving support and for joint counselling.

A striking feature of the group was that it mainly consisting of men and women over 35–40 years of age, even though the HIV prevalence in the area was very high among young adults 18–24 years of age. How come they never showed up at the group? After some informal chats with group members, the reason was clear. Just up the street, the church was running some vocational training programmes and income generating activities for urban poor. It turned out that PLWHA were not admitted to these programme. In other words, the younger PLWHA could not afford to be associated with the PLWHA group and had to conceal their status, as they were dependent on the training and income from the activities in order to sustain themselves and their families. When the church leaders were confronted with this, they were aware of the practice. They had not realized either the ethical dilemma or the mixed messages that the church was putting out.

Similarly, a UNAIDS sponsored Theological Workshop Focusing on HIV/AIDS Related Stigma in Namibia, December 2003, stated:
In relation to HIV and AIDS, experience has shown that the best form of prevention is truthful education. This applies to ‘truths of fact’ (what HIV is, how it is transmitted, how it can be prevented, and what will happen if a person becomes infected); but it also applies to ‘truth of meaning’, which is a theme which churches are well fitted to explore. ‘Truth of meaning’ relates to the meaning of suffering, the nature of sin, the relationship between life and death, and the search for the mind of God.

There is an urgent need to build communities that are welcoming, supportive and capable of breaking the silence about HIV and AIDS. Many churches are committed, in principle, to doing this. But it is hard to see how they can succeed without some painful soul-searching at the level of the institutions themselves, as well as of their hierarchies, clergy and members. For churches, truth-telling may involve an acknowledgement that they have been party to stigmatisation. They may have advocated ‘bad theology’ or failed to challenge it. They may have condoned a climate of silence and denial at institutional level, diluted or misrepresented the facts in their educational programmes, failed to provide strong, prophetic leadership, and been responsible for the poor moral example which sometimes exists within the churches themselves. It must be remembered that Jesus was particularly critical of religious people when he caught them out in hypocrisy 13.

If churches are to engage effectively with local, regional and international responses to the epidemic, then issues of stigma and discrimination have to be confronted, not just at the level of church organization and practice, but also by Christian theology itself: at the level of what is taught in seminaries, what academic theologians lecture, write and think about, what the faithful believe and do, and what values inform the pastoral formation of clergy and lay people 14, But this puts great pressure on those who teach in these contexts, who may know little or nothing about HIV or AIDS, and whose own background and training is unlikely to have provided them with the tools for reflecting theologically upon it 15. There are some practical materials available which are written specifically on a theological response to HIV/AIDS 16; however, more churches need to develop curricula with input from the lived experience of PLWHA that focus on a theology of compassion, support and healing related to HIV/AIDS and which discusses judgement and condemnation.

Finally, the struggle for humanity is to celebrate differentiation by enabling it to be equally enriching in community. Unless Church leaders are willing to be with the stigmatized publicly and consistently, then our actions will not be credible or effective 17.

2.2 Looking inside the PLWHA movement

Around the world, when HIV has appeared, PLWHA have often established networks or groups of self-help, support and empowerment as well as organizations, generally based on the notion of “positive living”, which involves the following.

Looking after spiritual health, for example asking the divine for strength, meditating, praying or seeking pastoral counselling.
Looking after mental health, for example, joining self-help groups, sharing feelings with family and loved ones, including children, thinking positively and renewing reasons to live.
Making good health choices, for example, getting medical help whenever ill, eating nutritious food, drinking plenty of water, practising good hygiene, taking extra rest when needed, avoiding smoking, alcohol and drug use, protecting the health of others by not exposing them to HIV infection, and taking antiretroviral therapy if medically indicated (this assumes that it is available).
Putting worldly affairs in order, for example, making peace with others, arranging for the care of children and making a will.
Living as normally as possible, for example working for as long as possible, spending time with friends and family, and staying active in religious, professional and community organizations.

Many people, both HIV-positive and others, recognize the importance of such a response to both a HIV diagnosis and an impaired immune system. It is striking a balance between life and the reality of death. Yet this response has sometimes been ignored or belittled by policy-makers and medical professionals. PLWHA have fought for their involvement in making decisions about their own health care, policy debates on both national and international HIV-related issues, and particularly on access to treatment

In June 1983 in Denver, United States, a movement of PLWHA emerged 18. The ‘Denver Principles’ adopted at the forum called for those living with HIV to be supported when they opposed AIDS-related stigma and discrimination.

These principles gathered greater support over time and were formally recognized in the principle of the Greater Involvement of People Living with HIV/AIDS (GIPA) signed by 42 countries at the 1994 Paris AIDS Summit. The countries agreed to support an initiative to “strengthen the capacity and coordination of networks of PLWHA and community-based organizations”. They added that, “by ensuring their full involvement in our common response to the pandemic at all—national, regional and global—levels, this initiative will, in particular, stimulate the creation of supportive political, legal and social environments”. The governments also undertook to “ensure equal protection under the law for PLWHA” 19.

In 2001, the United Nations General Assembly Special Session on HIV/AIDS in the Declaration of Commitment endorsed the GIPA principle 20, which was further upheld in the Guiding Principles of the “3 by 5” Treatment Initiative, which aims to provide three million people with antiretroviral therapy by the end of 2005 21.

In section “4.4 Tokenism”, the texts of declarations and strategic plans by churches and faith-based organizations, which require or promote the involvement of PLWHA, are set out.

Despite these pledges and commitments, the active involvement of PLWHA in decision-making relevant to their lives is still far from universal. Furthermore, the involvement of HIV-positive women, youth and children has lagged far behind that of men in most parts of the world. One constraint is that, globally, only about 10% of PLWHA know their seropositive status, and many other PLWHA are unwilling to be open about their status because of fear of discrimination and stigma.

PLWHA organizations also have their limitations and weakness. Firstly, the majority of PLWHA do not belong to PLWHA organizations, which raises the issue for both the church and PLWHA organizations of how to bring PLWHA into some form of support group. Secondly, how do church and PLWHA organizations respond to angry, isolated or desperate PLWHA who knowingly put others at risk of HIV infection or, in some regions, who may have sex with virgins in the belief that this will cure HIV infection? How do church and PLWHA organizations respond to authoritative, HIV-positive husbands or partners who insist that their wives or partners provide unprotected sex? Such acts are the effects of unjust social structures and stigmatized, isolated, rejected and silenced PLWHA. Partnership with PLWHA organizations will offer both PLWHA and churches a way forward, through creating an environment where discussion of taboo subjects can take place and cooperation on finding solutions for HIV- and AIDS-related stigma that places many PLWHA in distressing situations.

PLWHA organizations face challenges like any other grouping of people. Unfair and discriminatory power dynamics can occur within the PLWHA organizations. For example, women in some support groups headed by men, often complain that public roles are given to men and that women are allocated jobs which do not pay much or are or given the unpaid jobs. Similarly, orphaned girl-children face greater challenges due to their gender and age. As a group, they are likely to be subjected to sexual violence, exploitation, human trafficking and face greater possibilities of dropping out of school due to work commitments, forced marriages or teenage pregnancy. Women and grandmothers who are HIV-positive due to their gender may be hindered from HIV education, access to information, services and resources Other challenges are associated with class, race, age, ethnic and sexual orientation.

Power struggles can lead to open jealousy, competition and conflict of interest may occur. In most countries; there is a history of internal fighting within PLWHA organizations, and conflict between organizations. While this is wasteful of time and resources, normally, the PLWHA movement that has evolved has been strengthened, though the cost is high. Unfortunately, this appears to be a normal part of the evolution of PLWHA movements.

PLWHA needs are not uniform – they reflect the diversity of PLWHA. PLWHA include HIV-positive infants, prisoners, orphans, widows, single women, migrants, poor or unemployed men or women, people dying from AIDS-related causes; older people, men who have sex with men, injecting drug workers, commercial sex workers, care-giving grandmothers, recipients of blood and blood products – in short PLWHA come from a broad spectrum of society. All these groups of PLWHA have different needs and they may form different organizations to reflect and address their particular experiences and needs, and may require particular forms of partnership.

The International Community of Women Living with HIV and AIDS (ICW)22 was formed as a result of women’s needs to have a support network which reflects their needs and experiences. In 2003, the UN Secretary General, Kofi Annan, established a task force to investigate the impact of HIV/AIDS on women and girls. This was part of a movement, which included the 2004 World AIDS Campaign focus on women and girls 23, and the formation of the Global Coalition on Women and AIDS initiative24. In 2004, the World AIDS Campaign slogan “Have you heard me today,” highlighted the unique and complex burdens of HIV and AIDS experienced by women and the girl-child due to their gendered identities 25. To help churches grasp the plight of many woman around the world; the Ecumenical Advocacy Alliance developed liturgy that encouraged the use of a poetic prayer, highlighting biblical women and their experiences, tying it together with the stories of contemporary women as shown in the following box.

Box 6: Have you heard me today? 26

Woman 1: I am Eve, the bone of your bone, and the flesh of your flesh.
Woman 2: I am Sarah, the woman who calls you Lord and master.
Woman 3: I am Hagar your maidservant; your unofficial wife, expelled from your house.
Woman 4: I am Leah, the woman you married against your will.
Woman 5: I am Dinah your only daughter who is raped by Shechem.
Woman 6: I am Tamar, your desperate widow who plays the sex worker.
Woman 7: I am Ruth, your young widow sleeping at your feet, asking for your cover.
Woman 8: I am Bathsheba, raped by your king and married by the same.
Woman 9: I am Vashti, your wife banished so that all women can obey husbands.
Woman 10: I am the Levite’s concubine, raped by the mob and cut up by my lover.

ALL Women:
We are the broken women of the Hebrew Bible
We are broken women in a broken world.
We are women searching for our own healing.
Have you heard us today?

Woman 11: I am Mary, the pregnant woman with no place to go.
Woman 12: I am the Samaritan woman, with five husbands and none for her own.
Woman 13: I am Martha, the woman who is cooking while you sit and talk.
Woman 14: I am Mary, the woman who silently anoints your feet with oil.
Woman 15: I am the street woman, washing your feet with my tears.
Woman 16: I am the bent over woman, waiting for your healing touch.
Woman 17: I am the bleeding woman, struggling to touch your garment of power.
Woman 18: I am Anna, the widow praying for liberation in your temple
Woman 19: I am the persistent widow in your courts, crying, “Grant me Justice.”
Woman 20: I am Jezebel, the demonized woman, blamed for all evil.

ALL Women:
We are women of the Christian Testament.
We are broken women in a broken world.
We are women searching for our own healing.
Have you heard us today?

Woman 21: I am the woman in your home, I am your wife.
Woman 22: I am the woman in your house, I am your lover, your live-in girlfriend.
Woman 23: I am the woman in your life, I am your mother.
Woman 24: I am a woman in your workplace, I am your secretary.
Woman 25: I am a woman in your streets, I am your sex worker.
Woman 26: I am a working woman in your house with no property of my own.
Woman 27: I am the woman in your life with no control over my body.
Woman 28: I am the woman in your bed with a blue eye and broken ribs.
Woman 29: I am the woman raped in your house, streets, offices and church.
Woman 30: I am the woman in your church, cooking, cleaning, clapping & dancing.

ALL WOMEN:
We are women of the world.
We are Women of Faith.
And we are secular women.
We are women seeking for our own healing
Have you hear us today?

Similarly, Young Positives came into being to address the needs of young HIV-positive people 27.

Chapter 3: Challenges for churches

This chapter explores in depth issues related to prevention such as the position of women and condom use for serodiscordent couples. The ‘ABC’ approach to prevention – Abstain, Be faithful, use Condoms – is discussed and particularly what “B” – be faithful, could mean if the church was more involved in the sex lives of its congregation. An alternate model to the ABC preventive approach is also provided.

Further sections explore the relationship between sex, HIV and sin, the need for churches to be open and positive about sexuality and pre-marital HIV testing. The final section focuses on drug use, and particularly injecting drug use, as a mode of HIV transmission.

Many of these issues are testing the compassion and AIDS competency of churches; often there are no easy answers. These issues have the potential to create obstacles to partnerships with PLWHA and between faiths. Even if some positions are contentious or unpopular, churches need to be able to articulate their positions with reason and coherently, so that all partners know where they stand in a relationship. While the material presented does specifically refer to partnerships with PLWHA, it has been presented so that churches and PLWHA organizations have clear statements of different churches positions and the theological underpinnings on an array of contentious issues.

3.1 HIV Prevention – sexual transmission

Churches and faith-based organizations continue to debate what constitute appropriate HIV prevention messages. While there is uncertainty regarding what the content of prevention messages should be, the caring and support role of faith-based communities in relation to HIV and AIDS is broadly accepted. For example, the Catholic Church and the Seventh Day Adventist Church 28 are heavily involved in providing medical care for PLWHA.

Covenant 1: Life and HIV/AIDS prevention 29

We shall remember, proclaim and act on the fact that, the Lord our God created all people and all life and created life very good (Genesis 1–2) We shall, therefore, seriously and effectively undertake HIV/AIDS prevention for all people - Christians and non-Christian married and single, young and old, women and men, poor and rich, black, white, yellow, all people everywhere-, for this disease destroys life and its goodness, thus violating God's creation and will.

The Siyam’kela study suggested that as many churches are struggling with how to deal with prevention, churches have found a safer response in providing for PLWHA’s welfare, in line with the traditional role of the church as a ‘carer’. It’s a very difficult one. I don’t know for how long we will be emphasising the problem of care and support and not on prevention. Because I think churches tend to want to address caring for the sick. I think that is important, but what do we do to make sure we have methods that will help prevent the spread of the virus? Faith leader 30

Indeed this perspective has long been viewed as a theological misfit. Dube writes:

There is no doubt that as a church we pride ourselves for our care- giving roles. We visit the sick, we pray for them, we counsel them and their relatives; many times we take care of the sick—we wash them, we pray for them, we feed them and when they die we bury them. We are also there for the orphans, doing all that is within our power to help. But the problem with our excellent ‘care programmes is that they lack an equally effective prevention programmes. This unbalanced approach castes the church (and its leadership) as an institution that focuses on symptoms. We only come in to manage crisis, but we do not deal with the root problem. What is even more problematic with this care-oriented picture is that it seriously puts doubts in our theology of respect for life, if at all it exists. If we really respect all life as sacred, if we really regard every human being, Christian or non-Christian, as made of God’s image—shouldn’t we demonstrate this theological stance by designing programmes that make us effective instruments in the prevention of HIV/AIDS as well? 31

The overarching prevention messages conveyed by churches and faith-based organizations are in line with religious teaching, that is, demanding abstinence before marriage and faithfulness within marriage. Box seven “Prevention: as addressed in Declarations” outlines the position and commitments of various churches around the world on some HIV prevention issues. Some of messages give life to the deeper issues of developing greater respect for one’s own body and for the bodies of other persons, especially persons with whom one engages in intimate relationships.

THE pastoral challenge of the Church in Africa, I suggest, is to develop a pastoral approach that forms and informs our people so that, in the depths of their being, they can decide about HIV – rather than being its victims in a passive or fatalistic manner. Instead of saying things like “AIDS happened to me” or “I didn’t know I was getting HIV or “I had sex but it wasn’t really my decision,” to take their stand as Christian youth and adults.

What I am expressing is an ideal, not a judgement, and I recognize that there are people, especially girls and women, who really have been victimized. But I am convinced that people can say “no” to HIV and AIDS, and I pray that from now on the Church will do everything necessary so that our people can decide maturely and responsibly. If they learn consistently to say “no,” HIV/AIDS will go away.

Let us help young people to learn about their bodies, about the drive to develop strong and even intimate relationships with others, along with the discipline needed to prevent those relationships from becoming manipulative or exploitive. Let us form consciences according to traditional Church teaching and promote appropriate interventions that strengthen the family, reinforce healthy norms, protect youth and encourage abstinence and mutual fidelity in an effective and sustainable manner. Let us try to reach the whole man and every man, since HIV/AIDS is an affair of the integral person: body, soul, mind and feelings, sexuality, family and community, relationships. Whether single or married or widowed, priestly celibate or vowed religious, the fundamental choice is whether to remain faithful or not 32.

The Symposium of Episcopal Conferences of Africa and Madagascar also placed such an emphasis, stating:

Besides teaching the morality of the Church and sharing her moral convictions with civil society, and besides informing and alerting people to the dangers of HIV-infection, we want to educate appropriately and promote those changes in attitude and behaviour which value abstinence and self-control before marriage and fidelity within marriage 33.

On World Aids 2004, Cardinal Javier Lozano Barragán, President of the Pontifical Council for Health Pastoral stated:

On many occasions John Paul II has addressed this question and has provided us with illuminating approaches that throw light on the nature of this disease, its prevention, the behaviour of patients and those who look after them, as well as the role that civil authorities and scientists should perform. I would like to emphasise his thinking as regards the immunodeficiency of moral and spiritual values and the accompanying of AIDS victims, to whom full care and services should be provided because they are the most in need. In particular, in his message for the World Day of the Sick 2005, the Holy Father emphasises that the drama of AIDS is a ‘pathology of the spirit’ and that for it to be combated in a responsible way it is necessary to increase prevention through education in respect for the sacred value of life and formation as regards the correct practice of sexuality 34

Box 7: Prevention: as addressed in the declarations of churches

In 1987, The World YWCA resolved that The World YWCA Council urge national YWCAs to establish programmes providing preventive health education on the subject of AIDS 35.

The Seventh Day Adventist Church in 1990, stated: “Adventists are committed to education for prevention of AIDS. Adventist support sex education that includes the concept that human sexuality is God's gift to humanity. Biblical sexuality clearly limits sexual relationships to one's spouse and excludes promiscuous and all other sexual relationships and the consequent increased exposure to HIV” 36.

Tthe Plan of Action formulated by the Ecumenical Response to HIV/AIDS in Africa (EHAIA) stated concerning prevention 37:
1. We will promote effective means of prevention, practices that save lives, and behavior that minimizes the risk of infection. In doing so, we will support the churches' historic commitment to faithfulness and abstinence, while recognizing that life may present us with contexts in which these ideals are unachievable.
2. We will always lift up, as the priority, those who are most vulnerable to the risk of infection, people living with HIV/AIDS, and those persons who are more broadly affected by HIV/AIDS.
3. We will encourage networking (among churches, faith-based organizations, international and non-governmental organizations, institutions of higher education, and governments) which aims to build relationships, and which maximizes the benefit and efficiency of prevention efforts.
4. We will promote voluntary testing and counseling. These play an important part in HIV education, offering constructive advice on life-protecting behavior, and clearing the way for resolutions regarding abstinence and faithfulness. They also help to overcome stigma. As churches, however, we will engage in dialogue and question the practice of mandatory testing (pre-marital and other forms) and its consequences for the person who is diagnosed as HIV-positive.
5. We will encourage and support creative prevention programs. These might include, clubs in parishes, schools and hospitals, especially for girls, and the utilization of schools as information and counseling centers.

The Pan-African Lutheran Church Leadership stated 38:

We commit ourselves to prevention.
We commit ourselves to examine attitudes and behavior that can cause
harm to our neighbor in the light of our Lutheran ethics.
We commit ourselves to taking a strong role to ensure prevention of HIV by assisting in efforts to reduce the spread of the pandemic.
We will speak the truth about the spread of HIV/AIDS and its prevention including the behavior change that is necessary.
We will not stand in the way of the use of any effective methods of prevention.
Listening to the Spirit of Truth, we make this commitment with the help of God.

The Council of Anglican Provinces in Africa (CAPA) stated 39:
Prevention saves lives.

We are committed to teaching our children and their parents life-preserving skills to inhibit the virus that causes AIDS. The time for preparation for sexual maturity is well before adolescence and the onset of sexual activity. Our energies must focus on our daughters and sons at an early age. While we know that information alone cannot save lives, information and action can.

Lutheran World Federation in the message from the Tenth Assembly stated 40:

Therefore, we commit ourselves and call on member churches to further awareness regarding prevention of the HIV/AIDS pandemic through education and information, including speaking-out against harmful, abusive and exploitative sexual practices, treating sexually transmitted diseases, promoting faithfulness in marriage and advocating effective means of prevention (e.g. abstinence, use of condoms, sterilized needles, clean blood supply).

The Interfaith: Christian Conference of Asia stated, “It is our common understanding that we should speak openly about the basic facts of the HIV/AIDS crisis and about all effective means of prevention” 41.

The Message issued by Symposium of Episcopal Conferences of Africa and Madagascar stated 42:

Let’s change behaviour.
Besides teaching the morality of the Church and sharing her moral convictions with civil society, and besides informing and alerting people to the dangers of HIV-infection, we want to educate appropriately and promote those changes in attitude and behaviour which value abstinence and self-control before marriage and fidelity within marriage. We want to become involved in affective and sexual education for the life to help young people and couples discover the wonder of their sexuality and their reproductive capacities. Out of such wonder and respect flow a responsible sexuality and method of managing fertility in mutual respect between the man and the woman.

This type of education can only be undertaken effectively with the active collaboration of lay men and women who not only speak about principles of morality but also, as youth and as couples, give living testimony that fidelity to these moral principles yields a humanising and fulfilling affective and sexual life. Such education also contributes to promoting healthy and stable families, and these are the best prevention against AIDS. Organizations 43 which specialise in such education for young people and for couples exist throughout Africa and are having a small but gratifying degree of success. We give them the support and encouragement they deserve.

The Lutheran World Federation and the United Evangelical Mission in the Statement of Commitment of the Asian Church Leadership Consultation on HIV/AIDS agreed:“Knowing that only through education and prevention we can curb the spread and effects of this pandemic, we commit ourselves to:

Integrate a good quality HIV and reproductive health education in the Christian Education curriculum to “ensure that young people have information and life skills they need before they become sexually active and sexual behavior starts to form.” This should also include adequate information about the protective use of condoms in the context of HIV/AIDS prevention, the danger of needle-sharing in intravenous drug use and other preventive measures;
Continue to promote fidelity in marriage in a context of gender equality and informed choices” 44.

In the Memorandum of Intention by Churches in central and eastern Europe stated, “The political, social and economic changes in Central and Eastern Europe throughout the last two decades have made certain population groups vulnerable to HIV/AIDS. We resolve to focus our church-related HIV/AIDS work on the following groups:

1. Children and Youth, including those who are orphans and/or homeless/street children
2. Women
3. Children born of HIV-infected Mothers
4. Prisoners
5. HIV-infected and affected Persons
6. Drug users

We will continue to assess the needs of other groups that may also be vulnerable to HIV infection.

The battle against the HIV/AIDS crisis is a battle for the dignity of life. It calls us to use all effective means of prevention within a context of Christian ethics” 45.

World Council of Churches’ Pacific Member Churches stated 46 “Whilst we are mindful of the ethical issues that HIV presents to the church, we are faced with a more urgent reality that drives us to consider the highest ethic, which is the preservation of life. The church lives in the context of the wider community and has a clear responsibility to adhere to the ethical principles that guide society.
We are therefore committed to address:

Prevention and Condoms – Condoms, when appropriately targeted and promoted, are scientifically proven to be an effective part of the prevention strategy against sexually transmitted infections. We are committed not to focus our efforts working against the use of condoms – but rather recognize the freedom for individuals to make informed choices and to have access to condom use.”

The International Interfaith Conference on Prevention and Control of HIV/AIDS in 2004 stated:

We reaffirm that the primary goal and task before all religions and faiths is to assist people to stay away from risk behaviour affecting their physical, moral and spiritual growth and development. This mandate before us when effectively fulfilled will equip every one to protect himself or herself and society against HIV/AIDS that has no cure or vaccine.

We recognize that Religions and Faiths have a mandate to light up the path of the youth since they have to carry the torch of life on its eternal journey. In facing the challenge of HIV/AIDS they are our best, first line of defence, while being the most vulnerable as well. We pledge to work with the youth in this fight.

We affirm that Religions and Faiths have a critical role in placing the scientific facts of HIV/AIDS in their due perspective. We recognize the importance of scientific efforts for developing effective vaccine against the epidemic and the need for requisite support for achieving a breakthrough in such efforts 47.

The Cairo Declaration from an interfaith meeting stated 48:

The family is the foundation for building and defending society. It is therefore necessary to encourage starting families in accordance with heavenly decrees, and we should remove all obstacles in the way.

We emphasize the need to break the silence, doing so from the pulpits of our mosques, churches, educational institutions, and all the venues in which we may be called to speak. We need to address the ways to deal with the HIV/AIDS epidemic based upon our genuine spiritual principles and our creativity, and armed with scientific knowledge, aiming at the innovation of new approaches to deal with this dangerous challenge.

We reiterate that abstinence and faithfulness are the two cornerstones of our preventive strategies but we understand the medical call for the use of different means to reduce the harm to oneself and others.

We view as sinful anything that may cause infection through intention or negligence – as a result of not using all possible preventive means available.

We emphasize the importance of reaching out to vulnerable groups which are more at risk of being infected by HIV/AIDS and/or spreading it, including commercial sex workers and their clients, injecting drug users, men having sex with men, and those who practice harmful behaviors. We emphasize the importance of diverse approaches and means to reach out to those groups, and although we do not approve of such behaviors, we call on them to repent and ask that treatment and rehabilitation programs be developed. These programs should be based on our culture and spiritual values.

We call upon the media to abide by ethical codes regarding the material they present.

We advocate the rights of women to reduce their vulnerability to HIV/AIDS.

Nevertheless, churches are faced with challenges in following the ‘abstinence and be faithful’ prevention strategy. Research on HIV transmission indicates that messages of abstinence and faithfulness do not adequately account for the issues facing communities 49; when they are promoted as the only forms of HIV prevention. Such prevention messages also focus exclusively on sexual transmission, ignoring other methods of HIV transmission such as injecting drug use. And an exclusive abstinence and faithfulness prevention message may reinforce views that PLWHA are sinners.

For years, secular prevention programmes for the general population have focused on the ‘ABC’ strategy – Abstain and delay sexual initiation; Be faithful (and be safer) or reduce the number of sexual partners; and use Condoms correctly and consistently. For many people, particularly women and girls, this approach is of limited value. They lack social and economic power, and live in fear of male violence. They cannot negotiate abstinence from sex, nor can they insist their partners remain faithful or use condoms.

Ironically, trust and affection within marriage and other long-term relationships are sometimes part of the problem. Studies from various parts of the world suggest married couples have sex more frequently than unmarried individuals, but use condoms less often. Global studies of relationships between sex workers and their clients show a similar pattern: condom use was less consistent if sex workers felt a level of intimacy with their regular clients. For example, in Kenya’s Nyanza Province, surveyed clients of sex workers reported using condoms less consistently if they were with their usual sex worker 50.

Vulnerability to HIV exposure – an individual or community’s inability to control their risk of infection – is multifaceted, so no single prevention intervention will be effective on its own. Key elements in comprehensive HIV prevention include:

AIDS education and awareness;
behaviour-change programmes, especially for young people and populations at higher risk of HIV exposure, as well as for people living with HIV;
promoting male and female condoms as a protective option, along with abstinence, fidelity and reducing the number of sexual partners;
confidential voluntary counselling and testing;
preventing and treating sexually transmitted infections;
primary prevention among pregnant women and prevention of mother-to-child transmission;
harm reduction programmes for injecting drug users;
measures to protect blood supply safety;
infection control in health-care settings (universal precautions, safe medical injections, post-exposure prophylaxis);
community education and changes in laws and policies to counter stigma and discrimination; and
vulnerability reduction through social, legal and economic change 51.

Comprehensive prevention addresses all modes of HIV transmission. Since HIV epidemics are extremely diverse across regions, within countries and over time, programme planners need to place different emphases on the mix of strategies:

in low-prevalence settings, prevention among key population groups (e.g., sex workers and their clients, injecting drug users, men who have sex with men) can be effective in keeping HIV at low levels across society;
in high-prevalence settings, prevention among key populations continues to be important, but broad strategies reaching all segments of society are needed to reverse the trend of the epidemic; and
in all countries, prevention is impeded if universal access to treatment, as well as impact and vulnerability-reduction measures, are not clearly parts of the response 52.

Churches and faith-based organizations are struggling with prevention messages when faced with the realities of sexuality and drug use in their congregations, particularly among the youth. As one faith leader questioned: Is it really possible for them (people) to totally abstain? I think there are a lot of things that we need to discuss as the church and see what actually works 53.

Another challenge facing faith-based organizations is the best strategy to adopt to promote HIV-transmission prevention within marriage. The feasibility of merely advocating faithfulness and rejecting the use of condoms in marriage has been questioned. See box eight “Women and HIV”. While some churches rejected the use of condoms, others feel that the occurrence of unfaithfulness in marriage is a reality that should be reflected in churches’ responses to HIV and AIDS. Certain churches and faith-based organizations, in light of the high rate of infection among married couples, serodiscordant couples, and the belief that some women are disempowered in intimate relationships, encourage married women to insist on the use of condoms to protect themselves from infection. For example, the Pan-African Lutheran Church Leadership, the Lutheran World Federation and the World Council of Churches’ Pacific Member Churches. See relevant texts in box seven “Prevention: as addressed in Declarations”.

Box nine “The Use of Condoms – Theological Perspectives” outlines different theological grounds underpinning different views on the use of condom in HIV prevention with in marriage.

Covenant 6: Gender Inequalities and HIV/AIDS 54

We shall remember, proclaim and act on the fact that the Lord our God, created humankind in his image. In his image, he created them male and female, he blessed them both and gave both of them leadership and resources in the earth; he made them one in Christ (Gen. 1:27 -29; Galatians 3:28–29). We shall, therefore, denounce gender inequalities that lead boys and men to risky behaviour, domination and violence; that deny girls and women leadership, decision making powers and property ownership thus exposing them to violence, witchcraft accusation, widow dispossession, survival sex – fuelling HIV infection and lack of quality care and treatment.

Box 8: Women and HIV

Women are twice as likely as men to contract HIV from a single act of unprotected sex, but they remain dependent on male cooperation to protect themselves from infection.

Women are particularly vulnerable to HIV, with about half of all HIV infections worldwide occurring among women. This vulnerability is primarily due to inadequate knowledge about HIV and AIDS, insufficient access to HIV-prevention services, inability to negotiate safer sex, and a lack of female-controlled HIV-prevention methods, such as microbicides. The female condom allows women some control but is not widely used and is relatively more expensive. In some of the regions worst-affected by AIDS, more than half of girls aged 15 to 19 have either never heard about AIDS or have at least one major misconception about how HIV is transmitted.

Across the world, between one fifth and a half of all girls and young women report that their first sexual encounter was forced. From a very early age, many young women experience rape and forced sex. Violent or forced sex can increase the risk of transmitting HIV because forced vaginal penetration commonly causes abrasions and cuts that allow the virus to cross the vaginal wall more easily.

Marriage is no protection against HIV. Across the developing world, the majority of women will be married by age 20 and have a higher rate of HIV infection than their unmarried, sexually active peers.

The “ABC” slogan – Abstain, Be faithful, consistently use a Condom – is the mainstay of many HIV prevention programmes. But for too many women and girls, this message holds no weight. Where sexual violence is widespread, abstinence or insisting on condom use is not a realistic option. Because of their lack of social and economic power, many women and girls are unable to negotiate relationships based on abstinence, faithfulness and use of condoms.

UNAIDS, World AIDS Campaign. Women, Girls and HIV/AIDS: Strategic Overview and Background Note, 2004. http://www.unaids.org/wac2004/tools.htm

Box 9: The use of condoms – theological perspectives 55

There is clear consensus among (Catholic) Church leaders on the norm and value of abstinence outside marriage. For example, Pope John Paul II told young people during his visit to Uganda in February 1993:

Do not let yourselves be led astray by those who ridicule your chastity or your power to control yourselves. The strength of your future married love depends on the strength of your present effort to learn about true love. Chastity is the only safe and virtuous means to put an end to the tragic plague of AIDS 56.

On the other hand, there appears to be a diversity of opinions among the hierarchy with regard to information and education about HIV prevention for those who do not share the Catholic tradition or who will not or cannot remain faithful to its teaching. The bishops of New Zealand, for example, refused to participate in a government-sponsored preventive education campaign:

Values cannot be separated from health, whatever people’s religious beliefs may be. The public is seriously misled if the impression is given that technical means alone can solve problems that require profound changes in human attitudes and behaviour … 57.

Other Church leaders, however, have advanced more flexible positions with regard to information about the use of condoms in preventing HIV transmission. In so doing, they explained that their intent was not in any way to compromise the fundamental values of the Church on marriage, but rather to respond to the current health crisis from a framework of traditional moral principles.

Thus the Administrative Board of the United States Conference of Catholic Bishops turned to the principle of toleration of a lesser evil in order to avoid a greater one when they foresaw the provision of information about condoms for those who might be prone to sexual acts which could put them or others at risk of HIV infection:

We recognize 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 58.

The bishops of Papua New Guinea signalled an openness to cooperate with their national government in order to facilitate a comprehensive approach to HIV prevention education:

Both the government and the Churches must play an active role in the prevention of disease since this is the only means to fight against the spread of the disease and so far there is no cure for it. They must give honest, complete information to everybody, because everybody has the right to know what HIV and AIDS is, what are the ways of transmission of the virus, and what are all the possible means of protection 59.

In a statement by its Social Commission, SIDA: La Société en Question (AIDS: Society in Question), the French Bishops’ Conference seemed to make use of another traditional moral argument, i.e., that of gradualism. This approach recognizes that individuals find themselves in differing stages of moral development and thus will require diverse solutions for moral challenges. Cardinal Lustiger of Paris seems to have paved the way for such reasoning when he stated in a public television interview on World AIDS Day, December 1, 1988:

You who suffer from this illness, you who cannot be chaste, use the means that are proposed to you, out of self-respect and out of respect for others. You must not cause death 60.

Many bishops and theologians have pointed out that, in all this discussion, the fundamental imperative to preserve life is primary. Thus Cardinal Schonborn of Vienna said, in commenting on the French Bishops’ Statement: Love can never bring death … In given situations, the condom can be seen as the lesser evil 61. Belgian Cardinal Godfried Danneels has spoken in favour of using condoms in certain circumstances to protect against AIDS, saying not using prophylactics could transgress the Biblical commandment which states, "Thou shalt not kill" 62.

Cardinal Simonis of Utrecht used the principle of self-defence when considering the situation of discordant couples: In this precise condition, and only in the realm of marriage and not in other situations, the condom may be seen as a form of self-defence. Cardinal Agré, Archbishop of Abidjan, advanced a similar argument in 1997: In our struggle, we prefer abstinence, of course... The use of condoms is specific in ethical cases when one of the partners knows that he is HIV-positive or ill. The bishops of Chad placed this issue even more squarely in the realm of individual conscience as well as of the intimate space between husband and wife:

It is up to each and everyone of us to train one’s conscience and to assume one’s responsibility according to the situation in which one finds oneself. Because ‘no one is bound to do the impossible’, spouses cannot be asked to abstain from sexual intercourse; we therefore understand that a person, through love, may be led to use the condom to protect himself/herself or to protect his/her partner. But everybody must understand that the condom does not provide 100% protection and that it does not ultimately solve the real problems raised by AIDS.

Within the context of preserving life and of self-defence, the use of the condom to avoid HIV transmission, especially in circumstances involving discordant couples and involuntary sexual activity, also has been seen from the perspective of the principle of double effect whereby the condom would not be seen as a contraceptive device but rather as the means to safeguard life which is threatened by a deadly disease agent. Two prominent theologians in Rome seemed to recognize such an approach when they considered the situation of a prostitute who insists on condom use with clients as long as she feels compelled to continue her commercial sexual activity. Father George Cottier, Secretary General of the International Theological Commission and theologian to the Papal Household, commented:

A woman [prostitute] who understands that she cannot put her life or the life of another in danger is a woman who has grown morally, in comparison to a woman who has no consideration for her health or the health of others … I personally think that one must take into account the fact that these circumstances lead to death. The principle fully holds: Do not kill 63.

Speaking about a similar situation, Maurizio Faggioni, MD, moral theologian and member of the Congregation for the Doctrine of the Faith, said: Only in this path of pastoral graduality is it possible to tolerate – here, Catholic ethics does not approve, but tolerates – the use of a prophylactic 64.

Finally, the Southern African Bishops Conference in a “message of Hope” in July 2001 stated:

There are couples where one of the parties is living with HIV/AIDS. In these cases there is the real danger that the healthy partner may contract this killer disease. The Church accepts that everyone has the right to defend one’s life against mortal danger. This would include using the appropriate means and course of action.

Similarly where one spouse is infected with HIV/AIDS they must listen to their consciences. They are the only ones who can choose the appropriate means, in order to defend themselves against the infection. Decisions of such an intimate nature should be made by both husband and wife as equal and loving partners 65.

Religious leaders can play a vital role in educating people about HIV prevention, over and above the current discourse of abstinence and being faithful to one partner. The ideal for religious leaders is usually the promotion of ‘sound family values’ and no sex outside of marriage; however, the reality for many people is very different 66. Religious leaders need to look more closely at making their teaching relevant to the everyday existence of their members.

HIV is fast changing the world in which we live, and churches need to change as well. AIDS is demanding that churches respond. How is a church in a country with 20% HIV prevalence dealing with 20% of its members being HIV-positive? Have church teachings on abstinence worked? The answer to the latter question is no, given the prevalence of HIV infection among believers. Simply, the fact that of the approximately 40 million people living with HIV and AIDS, 30 million are Christians, means that we have to get churches to take action. The church is just as affected by AIDS as society around it. If we can get the churches to fight the illness rather than those who are ill, then we will have achieved a lot. If people who are HIV-positive are integrated into church life, or if pastors can speak openly in their parishes about being HIV-positive themselves, then we will have achieved a great breakthrough 67.

Responding to AIDS does not mean that traditional teachings are irrelevant; but rather that teachings need to be given without judgement and adapted to fit today’s lived realities. For example, box 10 below describes the African Network of Religious Leaders Living with or personally affected by HIV and AIDS model of HIV prevention and care, which offers a comprehensive HIV prevention and care approach.

Box 10: HIV prevention and care: an alternative model

Some of the messages given to mitigate the spread of HIV have sadly added to the stigma. “ABC” is one such message 68. Within the African Network of Religious Leaders Living with or personally affected by HIV and AIDS (ANERELA+), a new model has been developed, called SAVE (Safer practices, Available medications, Voluntary counselling and testing, and Empowerment through education).

HIV prevention will never be effective without a care component and the SAVE model combines both prevention and care components as well as providing messages to counter stigmatization. HIV is a virus not a moral issue. As such the response should be based on public health measures tempered by human rights principles.

S refers to safer practices covering all the different modes of HIV transmission. For examples, safe blood for blood transfusion, barrier methods for penetrative sexual intercourse, sterile needles and syringes for injecting, safer methods for scarification and adoption of universal medical precautions.

A refers to available medications. Antiretroviral (ARV) therapy is by no means the only medical intervention needed by people living with HIV or AIDS (PLWHA). Long before it may be necessary, or desirable, for a person to commence antiretroviral therapy, medical needs concerning opportunistic infections and pathology tests arise. Treating opportunistic infections results in better quality of life, better health and longer term survival. Of vital importance to every person are good nutrition and an adequate supply of clean water, and this is doubly so for PLWHA.

V refers to voluntary counselling and testing, one intervention which may mitigate HIV-related stigma and increase the effectiveness of HIV prevention efforts. A person who knows his or her HIV status is in a better position to protect him or herself from infection or from infecting another, depending on the person’s status. In addition, someone who is HIV-positive can be provided with information and support to live positively. People who are ignorant of their HIV status or who are not cared for can be sources of new HIV infections.

E refers to empowerment through education. It is not possible to make an informed decision without all the facts. Misinformation and mis-action are two of the greatest factors driving HIV- and AIDS-related stigma and discrimination. Correct information needs to be disseminated to all within churches so as to ensure that people respond to others through knowledge and from a perspective of Christ centred love. This will assist people to live positively – whatever their HIV status – and break down barriers which HIV has caused between people and within communities. Education also includes information on good nutrition, stress management and the need for physical exercise.

Clearly, ABC has come under much scrutiny, including the need for additional prevention methods to be included, for example, D for drugs; E for education, F for fighting contaminated needles and G for good practice of medicine . However, some of the more potential positive benefits of the ABC strategy have perhaps not been fully explored. Box 11 “Better sex as a solution to prevention of HIV infection in relationships: the B in ABC” opens up the question of satisfying sexual relations within a relationship and explicitly raises the question for churches and faith-based organizations – what is their role in ensuring that their congregation live full and satisfying sex lives, both for their physical and spiritual wellbeing as well as an effective mode of HIV prevention.

Box 11: Better sex as a solution to prevention of HIV infection in relationships: The ‘B’ in ABC 70

Reflections by David Patient, a PLWHA, and Neil Orr, who worked with a specific church in Mozambique - from the very highest levels to the lay preacher as well as about 200 people from Vida Positiva Training. Once the feed back was assessed then started the education of the lay preachers around 'Tantric sex' [name later changed due to objections] and the subsequent feedback from the ministers was quite profound.

The objective of this article is to introduce an HIV prevention strategy that may actually work in married and other committed relationships: Teaching committed couples how to have better sex, this reducing the need and incidence of infidelity. And yes, this implies the absence of condoms. Why?

We need to distinguish between relationships with procreation versus recreational sexual objectives in HIV education and prevention strategies. The reason is simple: Couples want babies, which means condoms are simply not used.

The statistics regarding condom use in this category of at-risk population speak for themselves: Condom use is high and effective – in youth and sex worker sectors, but not elsewhere, at least in the developing world. As stated, the reason is simple: People want children when they get married or commit to each other in the long term. This aspect of committed relationship is deeply entrenched and reinforced culturally and via religious institutions.

At the same time, the statistics show that a woman who gets married increases her risk of HIV infection the day she gets married, because she loses the cultural and religious right to protection (i.e., condoms) when she gets married: she now needs to conceive. The question is: how do we protect her, her husband, and her children.

Here are the realities we have encountered

Often, it is considered acceptable for the husband to have extramarital sex, as long as he provides for his family. We do not agree that this is an intrinsically traditional cultural norm. Our experience is that this norm is relatively new.

The wife may not prevent conception through condom use. The situation is not the same as contraception through other means, which are largely invisible to the husband. A condom requires his full attention and participation, which rarely occurs; the consent of the husband is the key to condom use. This can be circumvented through the use of femidoms (female condom), but they are difficult to obtain, relatively expensive, and conspicuous unless carefully used. The husband's consent is only obtained – sometimes – after after several children have been born, and the couple assured that the procreation aspect of their relationships is fulfilled. What do we do till then?

If a man asks his wife to have sex other than in the standard missionary position, she may accuse him of treating her like a sex worker and be offended. Often she will go to her mother to complain who in turn will go to the husband's father and he then questions his son as to why he is treating his wife with such disrespect.

So this is the man's justification for having sex outside the marriage: 'I want better sex with my wife, but she won't let me have it.'

The next logical step was for us to speak to the wives. So we did, and asked why they refuse to have sex other than in the standard position, the response was that 'I am never asked what I like in sex, if I like sex and if I even want sex so why should I do anything that gives him pleasure. He doesn't care about me and my sexual needs so I will simply lie there, let him do his business. Why should I give him pleasure? If he wants that then he must use a working girl.' So it's a case of two wrongs and neither making a right.

We are aware that these reasons are the surface rationales that disguise a range of dysfunctional communications and role definitions for men and women in sexual relations. For example, it is common practice to suppress sexual pleasure in women, whether through the practices of 'dry sex' (i.e., removal of vaginal fluids before sex, to maximise friction – thus pleasure – for the man); clitoral circumcision, and so forth. For women, sex is often painful, and few connect it with pleasure.

The only conclusion we can arrive at is the following: Neither husbands nor wives particularly enjoy sex with each other. Furthermore, there is anger and resentment from both sides regarding this situation, which leads to high-risk sexual activities outside of the marriage. Is it much wonder that there is such resistance to sex education, if it is a source of frustration and often – for women particularly – pain?

Furthermore, if a wife does not conceive and bear children, she is often rejected by not only the husband, but by the community too. When this situation is placed within a context of gender inequity and often strong cultural and religious role definitions regarding sex, it appears that the situation is extremely difficult to change, at least from a HIV-prevention perspective.

Here is what we propose as a solution
What if the structure of religion was engaged to teach people in committed relationships how to have better sex? What if religion started taking an active role in human sexuality and relationship-building through educated intimacy? Sounds simple, but when you think through the methodology, it will become abundantly clear that this approach will also have a radical impact upon gender inequity, for the simple reason that the best sex is dependent upon a disciplined effort to communicate and learn about your sexual partner.

Why religious structures, such as ministers and priest? The reasons are more practical than anything else: Religion as an institution is the most vulnerable to the impact of HIV/AIDS in their married congregation.

Quite simply put, the very institution of marriage is under threat. By endorsing and facilitating marriage, churches are facilitating women – in particular – in shifting to a higher HIV-infection risk category.

Under the banner or morality (e.g. no sex before marriage; go forth and multiply, etc), religion is putting women at risk, unless they simultaneously provide the practical methods for avoiding such risks.

Protestant morality permits condom use within marriage, but still supports marriage as the appropriate place for procreation; Catholics do not permit condoms within marriage, and the same can be said for other non-Christian religions. It is true that all main-stream religions strongly discourage infidelity. So they think they are off the hook on the morality aspect.

Not quite: it is an illusion – and currently, a life-threatening one – to pretend that committed relationships will endure through simple 'thou shalt not' proscriptions. It is time that the religious institutions started figuring out what 'thou shall do', to prevent the disintegration of the sacred nature of marriage. The time for shouting the moral odes from the side-lines of sexual activity is over, unless you are content to see the game end, permanently. It's time for religion to update it's commitment to protecting the sanctity of marriage, and getting a little more involved in the mechanics of the process. People – married people – need help, and they need it from people they trust. It is not acceptable that people are told where (married, not married) they can have sex, without any instruction on how sex can be experienced as sacred.

This is where religion can play a huge corrective role in this pandemic

Imagine the following: a young couple approach their families to inform them that they are in love, and intend to get married. The families are delighted, and make an appointment with the minister/priest of their religion

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