Condoning condoms

Jean Paul II’s refusal to allow condom use to protect against HIV and sexually transmitted diseases has come under fire in many parts of the world. Not surprisingly his successor, Pope Benedict XVI seems to share the same views.

In his 1988 letter to the US Conference of Bishops, the then Cardinal Ratzinger stated that “with educational programs promoted by the civil government, one would not be dealing simply with a form of passive toleration but rather with a kind of behaviour which would result in at least the facilitation of evil”.

He went on to say that Catholic schools and institutions should not “condone practices which are immoral, for example, technical instructions in the use of prophylactic devices” (otherwise known as condoms).

Some have claimed that this criticism of the Church is unfounded. Some also claim that condoms don’t work anyway, or that they lead to promiscuity.

Supporters of these views often cite the turnaround in HIV infection rates in Uganda as proof of the benefits of abstinence and fidelity only. Uganda is one of the few success stories in sub-Saharan Africa where, at the peak of the epidemic in 1992, nearly 30 per cent of antenatal women in the capital Kampala, were HIV positive. By 2000, the figure was just above 10 per cent.

According to Ugandan President, Yoweri Museveni, a key supporter of Uganda’s AIDS program, success has been due to delaying girls’ first sexual encounter: in 1986 it averaged 14 years, in 2000 it had increased to 16 years. Sex with non-regular partners has also decreased, and use of condoms with non-regular partners has risen from 57 per cent in 1995 to 76 per cent in 1998. Since 1990, when HIV testing and counselling facilities were introduced, 450,000 Ugandans have volunteered for testing.

The solution was not only abstinence (in this case delayed onset of sexual debut) and fidelity (in this case reduction in sexual partners). It was multi-faceted, and as President Musevini says, it did include condoms and HIV testing and counselling. Having led a survey of 1,000 households in Uganda in 1991 to gather information on people’s knowledge of HIV-AIDS and their attitudes to sex, I am convinced that only a multi-faceted program could have worked.

I am always interested in the assertion that promoting condoms leads to promiscuity. Let’s leave aside the weight of the scientific evidence that says that it is untrue, and think this through. Do those that support this assertion really think condom promotion makes you more likely to have more sex? Have they ever used one? Condoms really can get in the way and they’re a bit messy. They can be a real hassle. Using them in fact would seem to indicate a greater level of mutual concern between the partners, rather than a wanton desire for sex. And as we have seen in countries all over the world, it is not easy to promote their use.

What do you tell a couple where one partner is infected with HIV? How much power does the woman have to refuse sex if she thinks, or even knows, her partner is infected? For example, Lori Heise, the director of the Global Campaign for Microbicides, tells us that in Ethiopia only 44 per cent of women feel able to refuse sex. Studies have produced similar figures in many other countries such as provincial Peru, Bangladesh, and Tanzania.

What are the ethical considerations then? Imagine you are a health worker and a woman tells you her story that she is faithful, but her husband has been tested for HIV and is positive - do you just tell her to be faithful, and deny her even the opportunity of encouraging her husband to use condoms? Is promoting condoms in this case the facilitation of evil?

This dilemma also shows us that not only do we need male controlled methods such as condoms, but that we also need to develop preventative methods, such as microbicides (substances that women can apply in the vagina prior to sex) that women can control themselves. And when effective microbicides are made available to women in poor developing countries will they be opposed by the Church on moral grounds?

Over the last three years there has been a welcome and huge increase in funding for the treatment of HIV in the developing world through the US President's Emergency Plan for AIDS Relief and the World Health Organization’s 3 by 5 program which set a target to get antiretroviral medicines to three million people in developing countries by the end of 2005.

Yet, even if we rapidly scale up treatment, expert modelling tells that it will never keep pace, unless we can prevent infections in the first place. So we not only need better and more accessible testing, counselling and treatment, we need much greater access to prevention services as well.

And as preventive measures I support the approaches of delaying the onset of sexual activity and mutual fidelity, but please don’t leave out options, such as male and female condoms, and microbicides when they come, that can help to stem the epidemic and save, over time, so many lives.

There is no doubt that we have real divergences of views towards condom use but there may be some changes in the Catholic Church’s stand. As reported recently in the International Herald Tribune, Kevin Dowling, the Archbishop of Rustenburg, is reported to advocate the use of condoms in dire situations, as in his very poor diocese in South Africa, where one in two adults are already infected. The Tribune also reports a greater interest by some of the senior clergy in discussing condoms. And Pope Benedict XVI has preached about openness and reconciliation in his first papal mass.

Let common and compassionate sense prevail.