The place of contraception remains one of the most hotly contested issues in the AIDS crisis. And the Roman Catholic Church is in the middle of the debate.

Catholic  teaching on the use of contraception to prevent new life is well known. The church opposes the use of any artificial means of contraception, including condoms, which would interfere with the transmission of life within any act of marriage.

This is the language of Humanae Vitae following on from Casti Connubii. Pope Paul IV’s 1968 encyclical and Pope Pius XI’s 1932 encyclical are both serious statements from the church. Both speak about sex only within marriage.
 

It is less well known that there is no official church position on the use of condoms to prevent transmission of a virus, or on the use of condoms outside marriage. The church has always taught that sex outside marriage is morally wrong, and it has no position on whether condoms would make it more or less wrong.

However, Cardinal Javier Lozano Barragan, the head of the Pontifical Council for Health Care Ministry, has recently been asked to conduct a limited study into condoms within marriage to prevent transmission of HIV. A study by this pastoral council would not have the status of church teaching, but might inform future teaching documents. In April this year Barragan said the document would be ready soon.

Part of the debate centres on what are called discordant couples. A discordant couple means a married couple, one of whom is infected with HIV. The term does not refer to how the infected partner was infected. The pastoral question is whether the church should teach that such couples may use condoms to prevent transmission of the disease, or whether they should be encouraged to embrace sexual abstinence.

“Certainly, it’s difficult. It’s tough to be able to maintain matrimonial chastity in this case,” said Camillian Father Felice Ruffini of the Pontifical Council for Health Care Workers. But in Ruffini’s personal view any allowance for condoms within marriage would be “an exception to Christ’s law,” and therefore illegitimate.

Sr. Mary Owens has spent almost 15 years helping to raise HIV-positive orphans at Nyumbani orphanage in Nairobi. In her view, Christ’s law has nothing to do with denying a normal sexual life to married couples who are HIV positive.

“You can’t say you can’t have sex for the rest of your life. Never have sex. They’re married,” said Owens. “The theological principles that can be invoked are time-honoured ones — the unjust aggressor, that you can protect yourself from someone who is dealing death to you; and the other one is the double effect. They’re not using a condom to prevent conception. They’re using the condom to prevent HIV from being transmitted.”

An argument rooted firmly in the way the Catholic Church has thought about moral questions over centuries has been advanced in favour of condom use within marriage by Jesuit Dr. Jon D. Fuller and Jesuit moral theologian Fr. James F. Keenan. Using the principle of double effect, these two thinkers on AIDS and moral theology argue it is morally correct to use a condom within marriage to prevent a fatal infection. By Keenan and Fuller’s reasoning:

• the object of this use of condoms — to preserve life — is not morally wrong;
• the wrong effect — contraception — may be foreseen but is not intended;
• the wrong effect is not the means to the right effect;
• there is proportionate reason for allowing the wrong effect.ABC stands for “Abstinence, Be Faithful or use Condoms.”
  

It was the slogan used in campaigns in Uganda which brought adult HIV-prevalence rates down from about 30 per cent in the early 1990s to eight per cent in 2002. Debate surrounds how much condoms contributed to Uganda’s drop in HIV-infection rates. There is evidence Ugandans changed their sexual behaviour, reducing the average number of sexual partners and delaying the sexual debut of young people. In 1988 50 per cent of females 15 to 17 years old had had sex. By 2000 that number was down to 34 per cent. There were smaller drops in these numbers for 18- and 19-year-olds. Condom use by unmarried men also rose from rates varying between zero and 14 per cent between 1988 and 1995 to 57 per cent in 2000.

While Western aid agencies have stressed condom promotion, many African leaders, including Ugandan president Yoweri Museveni at the last World AIDS Conference in Bangkok, have expressed doubts about condoms as the definitive public health intervention against AIDS. Recently, Kenyan first lady Lucy Kibaki told school girls in Nairobi they should delay sex until after marriage, and forget about condoms.

“You know how you can be infected with HIV/AIDS, yet some of you do those things which you know if you do you will get the virus. I am not telling you to use condoms. I am not in favour of condoms,” she said.

Jesuit Father Michael Czerny wishes Western aid agencies and international bodies would take Africans seriously when they speak in favour of abstinence and marriage rather than condoms.

Jesuit Father Dick Cremins, who has pioneered natural family planning education in villages in Malawi, can’t fathom the idea of the church pronouncing itself in favour of condoms for sex outside marriage.

“As if some fellow out committing adultery is then going to use a condom because the Pope says so,” laughs the old Irish missionary.

Though it does seem strange to imagine the Pope recommending better and safer ways to commit sins, the church has a history of meeting the poor and the outcast — including prostitutes and addicts — and helping them gradually embrace the life God gave them instead of the life the economy, their education and their addictions left them.

“The public health challenge is about saving as many lives as possible. That’s why there’s public health,” said Dr. Prabhat Jha, founder of Global Health Research, an independent institute which researches AIDS issues at Toronto’s St. Michael’s Hospital.

Jha argues that on the basic level of preserving human life, religious institutions and public health workers have common ideals and goals.

“Careful religious scholars have also said this, that you want to make the message that there is an ideal about respect for institutions like marriage, respect for not being untruthful to a life partner. Those are important principles, and they’re also universal — they’re not Christian, Muslim or Catholic, they’re universal,” Jha said. “But human behaviour is such that one can’t change all of the pressures we’ve got for having non-regular partners.”

Jha designed the HIV-prevention program for south India which drove down skyrocketing HIV rates in the 1990s. His program focussed on educating prostitutes about the risks and getting them to use condoms with all their customers. Jha doesn’t expect churches to distribute condoms on Sunday morning. He just hopes church institutions will support saving these women’s lives, and the lives of their customers.

Somewhere between the ideal of faithful marriage and the sad history of sin, Jha wants space for what he calls the most effective public health strategy available.

“The thing that we’re asking, I think, is so modest in the way of behaviour change, and yet so effective,” he said. “It doesn’t really increase sexual promiscuity. The evidence suggests so. And it can save a lot of lives.”  

Before she came to Nairobi’s Kangemi slum to co-ordinate Caritas Italia activities in Kenya, Maria Chiara was a psychologist working with prostitutes in Italy. She does not doubt targeting sex workers and other high risk groups with safe sex and condom messages has reduced HIV-infection rates in places such as Bangkok or south India, where prostitution is organized and segregated in red light districts. But the prostitution she’s seen in slums around Nairobi is not the same as prostitution in other parts of the world.

“You don’t have categories of people, like in Europe,” said Chiara.

Prostitution in Nairobi’s slums isn’t something women take up as an alternative form of work, but something which happens to them in the midst of homelessness and hunger for themselves and their children, she said. And it might happen to any woman in the slums. A woman may cook food for a man just in order to eat some of it, or feed her children. She then pays for the food by playing the part of a wife for a few days — or for as long as food and shelter remains available. It can be a grey area somewhere between prostitution and a relationship that mimics marriage.

“If prostitution is out of poverty, why can’t we do something to change that situation?” Chiara asks.

Chiara also questions whether a public health strategy which targets risk groups will work for a generalized epidemic.