The Pope’s comments on 17 March about the ineffectiveness and unacceptability of condoms to fight HIV and AIDS in Africa, and the reactions to them reverberated across the globe. Though reiterating a long-standing position proclaimed by the Catholic Church, propounded through billions of dollars within programmes supported by the propagation of the US President’s Emergency Plan for AIDS Relief (PEPFAR), those reactions were overwhelmingly negative – with the exception of the 13 May expression of support from the President of Symposium of Episcopal Conferences of Africa (SECAM)(Catholic News Agency, 13 May 2009). These comments and the outcry against them, however, offer an opportunity to explore them in the context of the HIV and AIDS epidemic especially in hardest-hit sub-Saharan Africa. Indeed, they highlight a schism in the response to the epidemic, drawn along the lines of acceptance and denial, of treatment and prevention, and of survival and living. Yet both sides, that of outrage and that of solidarity, seek the moral stance of protecting the dignity of life.

At this stage in the epidemic – progressing through phases of discovery, prevention, and treatment, and by many indications returning to emphasis on prevention – acceptance and treatment have become almost synonymous. Since the late 1990s, antiretroviral (ARV) treatment has become increasingly available, even in sub-Saharan Africa, by some arguments making HIV and AIDS a chronic, manageable disease. More and more resources have been poured into ARV treatment: in addition to PEPFAR, there is the Global Fund to Fight AIDS, Tuberculosis and Malaria, private foundations such as the Clinton Foundation and the Gates Foundation which procure and sometimes subsidise the medications, the World Bank, and individual countries themselves provide funding. Despite this, more funds are required to meet the current treatment needs, and even more beyond that will be necessary to fund the increasingly necessary second- and third-line treatment regimens, as drug resistance continues to rise and resistant forms of the virus spread.

In an effort to address these issues from the treatment position, acknowledging and accepting that HIV and AIDS exist and constitute a problem, a number of new options are being explored. The first proposal is to provide a daily dose of ARV treatment – pre-exposure prophylaxis (PEP) – to those at high-risk of HIV infection. “Safety and cost-effectiveness will be important factors to consider even if the approach proves effective in preventing infection,” (1) but does little in terms of protecting against the likely consequent development of resistance (the more exposure to ARVs, the more opportunity the HI-virus has to mutate and evade these), and in fact might accelerate this process. Furthermore, this intervention requires enormous capacity, in terms of identifying those most at risk, reaching them, and providing them with the prophylaxis, and comes at a huge financial cost.

The second would “involve universally available, voluntary, annual testing for HIV infection and immediately providing antiretroviral therapy for those who test positive. The potent combinations of antiretroviral medicines available today can suppress the amount of HIV in an infected person’s body” (2) even to undetectable levels, resulting in greater longevity and quality of life – and presumably productivity – and also theoretically to lower rates of transmission. However, in an important caveat, even annual testing risks missing the most infectious six-week-to-three-month window where most transmission occurs (until AIDS sets in, where higher rates of transmission recur), and the capacity and costs of such testing treatment would again be enormous.

The third aims towards a cure, albeit one that falls short of a vaccine. Such a ‘cure’ would be a ‘functional cure’, and would “suppress the virus to such low levels that an HIV-infected person would no longer need treatment because his or her immune system could keep the residual virus in check,” (3) though whether this would work against a constantly mutating virus remains to be seen. Assuming this would be possible, and could be applied within the initial, high-transmission rate window, it would bring with it a certain promise in the fight against HIV and AIDS. Yet, “just the research to determine feasibility would be extremely costly.” (4) Thus, though the treatment approach acknowledges the acute reality of HIV and AIDS, it might not represent the best – and certainly not the only – response to the epidemic. Indeed, given the current global financial crisis, many of the existing let alone planned treatment interventions hang in a (negative) balance. As such, the incidence and death rates wrought by HIV and AIDS, especially in sub-Sahara, belie chronic or cure-all of the treatment position: HIV still stalks the continent and still brings death.

This very persistent reality opens the door to denial and with it emphasises the necessary primacy of prevention. Denial might be invoked as a cover for such devastation. It might be used to turn a blind eye to the sexual relationships – individual and networked – that spur transmission. This is the crux of the problem with the Pope’s remarks. Ironically, his call for the “humanisation of human sexuality” does not make allowance for its lived variances – a vital precondition for both fighting HIV & AIDS and for expressions of morality. According to Richard Delate, country programme director for JHHESA who was quoted recently in Plus News (link to http://www.plusnews.org/Report.aspx?ReportId=83283): “A lot of South Africans interpret faithfulness as meaning they’re protecting their main partner from knowing about their other partners,”- this is an interpretation with necessarily profound consequences for sexual relations and the transmission of HIV, particularly within marriage. Consequently, the Pope’s stance appears to disregard the conditions facing Africans around HIV and AIDS.

While the two sides of the debate seem to counter each other, given the improbability of a miracle-cure offered by any of the three posited, they might perhaps converge to contribute to a more effective and holistic response to HIV and AIDS. Indeed, taking score of the persistent reality of the deadly epidemic, on the one hand, numerous Catholic priests and nuns working to support the survival and life of already HIV-infected individuals in Africa have rejected the Pope’s and the Catholic Church’s prohibitive stance against condoms (Kaiser Daily HIV/AIDS report, 18 March 2009. On the other hand, appealing to the possibility of a perfect morality, the president of SECAM, Cardinal Pengo, and other fellow African priests, iterated their support of the Pope and Church, arguing that the best way to fight HIV is “a responsible and moral attitude toward sex”, including “fidelity in marriage, chastity and abstinence from premarital sex as key weapons in the fight against AIDS.” (Catholic News Agency, 13 May 2009) One approach might be realistic, the other utopian, but both attempt to protect the life – physical and spiritual – of in this case Africans infected and affected by HIV & AIDS.

What can be done?

So while ARVs might not provide a sustainable ‘cure-all’ response to the accepted reality of the HIV and AIDS epidemic, neither does denial, the ramifications of which are worse. However, prevention does need to resurface as a priority, perhaps coupled with treatment – but not treatment as the preferred solution. Here the new South African ‘Scrutinise’ ad campaign urging (condom-users) to “flip HIV to HIV victory!” offers a valuable lesson. These rightly accept the reality of HIV, focus on prevention – ultimately more effective and cost-efficient than treatment – and promote survival and life, instead of dwelling on fear and death.

Annamarie Bindenagel Šehović is an external consultant for the HIV & AIDS in Africa Unit at CAI. She is also currently involved in collaborative research with Warwick University, UK, focusing on HIV and AIDS, global health and health sovereignty in the context of regionalism and globalisation.

NOTES:
1. See Anthony Fauci (2009) A Policy Cocktail for Fighting HIV, The New York Times, 16 April.
2. Ibid.
3. Ibid
4. Ibid.

The Pope’s comments on 17 March about the ineffectiveness and unacceptability of condoms to fight HIV and AIDS in Africa, and the reactions to them reverberated across the globe. Though reiterating a long-standing position proclaimed by the Catholic Church, propounded through billions of dollars within programmes supported by the propagation of the US President’s Emergency Plan for AIDS Relief (PEPFAR), those reactions were overwhelmingly negative – with the exception of the 13 May expression of support from the President of Symposium of Episcopal Conferences of Africa (SECAM)(Catholic News Agency, 13 May 2009). These comments and the outcry against them, however, offer an opportunity to explore them in the context of the HIV and AIDS epidemic especially in hardest-hit sub-Saharan Africa. Indeed, they highlight a schism in the response to the epidemic, drawn along the lines of acceptance and denial, of treatment and prevention, and of survival and living. Yet both sides, that of outrage and that of solidarity, seek the moral stance of protecting the dignity of life.

At this stage in the epidemic – progressing through phases of discovery, prevention, and treatment, and by many indications returning to emphasis on prevention – acceptance and treatment have become almost synonymous. Since the late 1990s, antiretroviral (ARV) treatment has become increasingly available, even in sub-Saharan Africa, by some arguments making HIV and AIDS a chronic, manageable disease. More and more resources have been poured into ARV treatment: in addition to PEPFAR, there is the Global Fund to Fight AIDS, Tuberculosis and Malaria, private foundations such as the Clinton Foundation and the Gates Foundation which procure and sometimes subsidise the medications, the World Bank, and individual countries themselves provide funding. Despite this, more funds are required to meet the current treatment needs, and even more beyond that will be necessary to fund the increasingly necessary second- and third-line treatment regimens, as drug resistance continues to rise and resistant forms of the virus spread.

In an effort to address these issues from the treatment position, acknowledging and accepting that HIV and AIDS exist and constitute a problem, a number of new options are being explored. The first proposal is to provide a daily dose of ARV treatment – pre-exposure prophylaxis (PEP) – to those at high-risk of HIV infection. “Safety and cost-effectiveness will be important factors to consider even if the approach proves effective in preventing infection,” (1) but does little in terms of protecting against the likely consequent development of resistance (the more exposure to ARVs, the more opportunity the HI-virus has to mutate and evade these), and in fact might accelerate this process. Furthermore, this intervention requires enormous capacity, in terms of identifying those most at risk, reaching them, and providing them with the prophylaxis, and comes at a huge financial cost.

The second would “involve universally available, voluntary, annual testing for HIV infection and immediately providing antiretroviral therapy for those who test positive. The potent combinations of antiretroviral medicines available today can suppress the amount of HIV in an infected person’s body” (2) even to undetectable levels, resulting in greater longevity and quality of life – and presumably productivity – and also theoretically to lower rates of transmission. However, in an important caveat, even annual testing risks missing the most infectious six-week-to-three-month window where most transmission occurs (until AIDS sets in, where higher rates of transmission recur), and the capacity and costs of such testing treatment would again be enormous.

The third aims towards a cure, albeit one that falls short of a vaccine. Such a ‘cure’ would be a ‘functional cure’, and would “suppress the virus to such low levels that an HIV-infected person would no longer need treatment because his or her immune system could keep the residual virus in check,” (3) though whether this would work against a constantly mutating virus remains to be seen. Assuming this would be possible, and could be applied within the initial, high-transmission rate window, it would bring with it a certain promise in the fight against HIV and AIDS. Yet, “just the research to determine feasibility would be extremely costly.” (4) Thus, though the treatment approach acknowledges the acute reality of HIV and AIDS, it might not represent the best – and certainly not the only – response to the epidemic. Indeed, given the current global financial crisis, many of the existing let alone planned treatment interventions hang in a (negative) balance. As such, the incidence and death rates wrought by HIV and AIDS, especially in sub-Sahara, belie chronic or cure-all of the treatment position: HIV still stalks the continent and still brings death.

This very persistent reality opens the door to denial and with it emphasises the necessary primacy of prevention. Denial might be invoked as a cover for such devastation. It might be used to turn a blind eye to the sexual relationships – individual and networked – that spur transmission. This is the crux of the problem with the Pope’s remarks. Ironically, his call for the “humanisation of human sexuality” does not make allowance for its lived variances – a vital precondition for both fighting HIV & AIDS and for expressions of morality. According to Richard Delate, country programme director for JHHESA who was quoted recently in Plus News (link to http://www.plusnews.org/Report.aspx?ReportId=83283): “A lot of South Africans interpret faithfulness as meaning they’re protecting their main partner from knowing about their other partners,”- this is an interpretation with necessarily profound consequences for sexual relations and the transmission of HIV, particularly within marriage. Consequently, the Pope’s stance appears to disregard the conditions facing Africans around HIV and AIDS.

While the two sides of the debate seem to counter each other, given the improbability of a miracle-cure offered by any of the three posited, they might perhaps converge to contribute to a more effective and holistic response to HIV and AIDS. Indeed, taking score of the persistent reality of the deadly epidemic, on the one hand, numerous Catholic priests and nuns working to support the survival and life of already HIV-infected individuals in Africa have rejected the Pope’s and the Catholic Church’s prohibitive stance against condoms (Kaiser Daily HIV/AIDS report, 18 March 2009. On the other hand, appealing to the possibility of a perfect morality, the president of SECAM, Cardinal Pengo, and other fellow African priests, iterated their support of the Pope and Church, arguing that the best way to fight HIV is “a responsible and moral attitude toward sex”, including “fidelity in marriage, chastity and abstinence from premarital sex as key weapons in the fight against AIDS.” (Catholic News Agency, 13 May 2009) One approach might be realistic, the other utopian, but both attempt to protect the life – physical and spiritual – of in this case Africans infected and affected by HIV & AIDS.

What can be done?

So while ARVs might not provide a sustainable ‘cure-all’ response to the accepted reality of the HIV and AIDS epidemic, neither does denial, the ramifications of which are worse. However, prevention does need to resurface as a priority, perhaps coupled with treatment – but not treatment as the preferred solution. Here the new South African ‘Scrutinise’ ad campaign urging (condom-users) to “flip HIV to HIV victory!” offers a valuable lesson. These rightly accept the reality of HIV, focus on prevention – ultimately more effective and cost-efficient than treatment – and promote survival and life, instead of dwelling on fear and death.

Annamarie Bindenagel Šehović is an external consultant for the HIV & AIDS in Africa Unit at CAI. She is also currently involved in collaborative research with Warwick University, UK, focusing on HIV and AIDS, global health and health sovereignty in the context of regionalism and globalisation.

NOTES:
1. See Anthony Fauci (2009) A Policy Cocktail for Fighting HIV, The New York Times, 16 April.
2. Ibid.
3. Ibid
4. Ibid.