ALTERNATIVE VIEWS ON HIV/AIDS
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- ALTERNATIVE VIEWS ON HIV/AIDS
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I
RF_DIS_2_N_SUDHA
2.^1
Use of Indian Traditional Drugs in HIV/AIDS A Scientific and Clinical Study
Ey.MKesavan, EY.Austin & EY.K.Raj^opalan
^4
Amala Ayurvedic Hospital
Dr/Kuttan and Sheeja T. Tharakan
Amala Cancer Research Centre
Human immunodeficiency virus (HIV) has been conclusively known to be the causative
agent for AIDS which is a major killer disease of the modern limes affecting almost 50 million
people around the world. The fact that the majority of the affected individuals arc from Asia and
Africa and that India is highly vulnerable to the disease make it very important in the national
priority in the medical strategy of the coming decade. Even after the intensive research of the last
decade, there are no effective remedies for the disease and the available one arc highly cosily
and is not affordable to the affected persons in India.
Il has been known that CD4 lymphocytes are mainly affected by the HIV when this class of
lymphocytes are destroyed, it produces an immunological imbalance in the body and weakens
the resistance to several opportunistic infections, consequently leading to death. The medicines
available at present produce a decrease of the viral load, but as they arc immunosupprcscnls they
can produce a deterioration of the patients immunity. Hence a search for non-toxic drugs that can
stimulate immunity and there by increase the body’s ability to fight the HIV infection arc being
sought.
Indigenous medicines in India are known fortheir action of stimulating the immune system.
Rasayanas which are preparations made either from a single plant or a combination of several
plants are known for their immunomodulatory properties. The immunoslimulating activity of
plants such as Tinospora cordifolia, Wilhania Sornnifera, Viscuin album, Emblica officinalis.
Semicarpus anacardium Asparagus racemases and Pueraria tuberosa have been studied in detail
and some of them arc being used in immunodeficient conditions such as cancer.
In Ayurveda a similar condition to HIV/AIDS has been mentioned which is known as
“Ojakshaya”, in which the fall in immunity may be due to other pathological condition for which
medicines have been prescribed. Charaka Samhila, Susrutha Samhita and Ashtanga Hrudaya
explain the function of ‘Ojas’ its symptoms, and the diseases caused by its depiction. 'Ojas’ is
otherwise explained as ‘Bala’ (strength) and ‘Dhatusara’. “Ojas” is of two types namely, ‘para
ojas’ and ‘Apara ojas’. The ‘ojas’ of para (excellent) type is eight drops in quantity and death
occurs when this get depleted. The other type ‘Apara ojas’ is also known as ‘slcshmaka ojas”,
the quantity of which is described as “Ardha Anjali”. When this ojas is not affected the bodily
functions will be normal. ‘Bala or immunity prevents in the body. ‘Ojas’ depletion occurs due to
the physical and mental causes such as a blow, a persistent wasting disease, anger, grief, anxiety,
fanliguc and hunger. “Jccvanceya oushadhas” - (certain groups of herbal drugs described in
ancient Ayurvedic texts as Jeevaneeya oushadhas) along with milk, meat soup can counteract
‘ojakshaya’.
HIV infection leads to break of immunity of the body. But this immunological breakdown
doses not occurs in every person in the same manner. According to the body strength, an infected
person may be free of symptoms upto 15 years. So it can be ascertained that one may not gel
AIDS when the immune mechanism is intact even if he is infected. ‘Ojas’ is the abstract part of
seven dhatus. Dhatus are the vital tissues of the human body. They are Rasa (Chycle), Raktha
(blood), Mamsa (flesh), Meda (fat), Asthi (bone), Majja (bone marrow) and Sukra (semen). So,
when there is adequate poshana (nourishment) of Dhatus the ‘ojas’ is maintained in the body.
For the proper nourishment of Dhatus, Dhatwagnies have an important role. As Dhatwagnies
are lhe nourishing enzymes ol Dhatus. Each Dhalu is being nourished by the help of Dhatwagni.
We have selected the drugs lor HIV/AIDS keeping the above points in mind- Three types of
drugs are selected for this study. They are Jeevaneeya, Bramhaneeys (maintaining or improving
body wt.) and Panchaneeya (or nourishing).
AIDS research was started by Amala Ayurvedic Hospital using in collaboration with Amala
cancer Research Centre in December 1992. A total no. of 700 HIV/AIDS cases were seen till 24-2002. On the basis of the known literature we have formulated 3 types of Ayurvedic herbal
preparations to counteract the ‘Ojakshaya’ seen in HIV/AIDS cases.
In the piesent study, we have evaluated the efficacy of the medicines in improving the
immune status of the HIV patients with AIDS related syndrome.
Materials and Methods
The study was conducted on patients in whom the HIV infection was confirmed through
ELISA and Western blot tests. For the clinical evaluation of medication 700 patients were studied.
Fordetailed study these patients were again classified into three groups. In the first group all the
700 patients were included. In the second group 45 AIDS symptoms patients were selected. In
the third group 11 AIDS patients were selected and their CD4> CD8 ratio and other immunological
parameters before and after treatment were done at CMC Medical College, Vellore and its details
will be presented by Dr. Ramadasan Kuttan.
Initial weight of the patient as well as the history, duration of contact and prior medication
were recorded.
Medication
Patient were given three types of medications formulated in our centre which are coded as
NCV-1, AC II andS.G.-III.
TABLE 1.
EFFECT OF AYURVEDIC DRUGS ON HIV-INFECTED (ARC) PATIENTS
Symptoms
No.of. Patients
with symptoms
Fever
____________ Patients 45 Total patient 45
Relief after treatment
Complete
Partial
No.of relief
Diarrhoea
45
11
33(79%)
9 (82%)
7(16%)
2(18%)
Cough
17
Lymphadenopathy
Glossitis
49
13
20
18
12
10
14
11 (65%)
45 (56%)
4(31%)
6 (35%)
4 (44%)
Loss of appetite
General weakness
Joint pain
Insomnia
Tuberculosis
Itching
12
Anorexia
6
2
4
Herpes exbaster
U leer penis/vegina
13 (65%)
15(83%)
10(83%)
7 (70%)
9 (69%)
5 (25%)
3 (17%)
2(17%)
9 (65%)
3 (30%)
4 (28%)
9 (75%)
4 (67%)
3 (25%)
2 (33%)
2(100%)
3 (75%()
1 (25%)
5 (5%)
2 (10%)
1 (7%)
NCV t and AC II are herbal powders while SG II is ghee based formulation. SG-III
formulation was avoided in patients who arc having very low appetite and dianhoea. Dosase of
the drugs are as follows.
!
1.
NCV-I
5 gm - twice a day with milk
2.
AC-11
5 gm - twice a day with milk
3.
SG-III
10 gm - morning and bed time.
Clinical details of group I patients
The total no. of cases studied were 700 out of this 530 were male, 162 were female and 8
were children.
Group 11 - Total patients - 45.
Clinical findings
Medication produced satisfactory relief of opportunistic infection and physical
ailments in patients. A summary of the relief of clinical symptoms is shown in the table I. The
drug produced satisfactory relief of fever, diarrhoea, joint pain, itching and produced partial
relict to lymphadenopalhy, glossitis etc. Moreover the drug produced a weight gain in most of
the patients and with feeling of well being.
In summary medication found to be useful in improving the immunological status in many
HIV patients with ARC with subsequent improvement in health. The drug also increased the life
span in many patients.
Conclusion
1.
2.
The total number of patients studied were 700.
Among the 700 patients 313 were HIV earners, 294 were AIDS symptoms patients and 93
were feel blown cases.
3.
4.
5.
6.
7.
8.
Il was seen that this disease mainly gels infected through sexual contact.
Medication was found to be useful in improving the immunological status in HIV patients
and as well as early stages of AIDS.
The drugs produced a weigh! gain in most of the patients and with a feeling of well being.
Drugs also increased the life span in many patients.
None of the patients become scro negative during the treatment.
Our drugs did not produce any adverse toxicity to the patients.
Body Weight 61*30 HIV patients before and after treatment
Years of Treatment
Before
No. treatment
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
57
52
50
82
87
78
46
52
49
48
39
42
68
47
37
1
2
3
4
5
6
7
8
9
61
52
47
90
102
78
42
55
51
41
44
42
65
44
41
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
48
68
56
39
63
55
43
63
11
43
50
51
64
51
43
56
55
45
55
14
41
54
4’ 0
21
45
48
41
34
44
59
Clinical Evaluation
For the clinicaRvaluation of the medication against H1V/AIDS, eleven patients were
studied. All the patients were positive to HIV-ELISA (Gene labs, USA) supplied by Ranbaxi,
India and were confirmed for positively using Western Blot (Gene Labs. USA) supplied by
Modi Biolcc, India and done in our laboratory.
The patients were examined by an Ayurvedic Physician and a medical doctor. All the
patients selected in the study have contacted with HIV either through sexual contact or through
accidentally using a contaminated blood product. Duration of the disease varied but the minimum
was 5 years. All patients selected in the study were symptomatic with AIDS related complex and
the symptoms varied from fever, lymphadenopathy, diarrhorea, skin rashes etc. and tuberculosis.
None of the patients selected had taken any other medication either Ayurvedic, homeopathic or
modern medicine specifically for HIV.
Initial weight of the patient as well as the history, duration of the contact, prior medication
were recorded. Patients were informed about the merits and demerits of the treatment given and
individual written consent was obtained.
Medication
Patients were given three types of medication formulated in our centre which arc coded as
NCV 1, AC II andSG III. NCV 1 and AC II arc herbal powders while SG III is ghee based drtm
(this formulation was avoided in patients who arc complaining gastrointestinal problems.) Dosage
of the drugs arc given below:
NCV I
5 gms twice daily with milk
AC II
5gms twice daily with milk
SG III
10 gms morning and evening
All the drugs and tests were given free of charge. Before starling the medication patients
were asked to undergo cell phenotype analysis at Dept, of Virology, CMC Hospital, Vellore.
This was done using FACS Scan, Becton Dickenson, USA using BD Simullcst Reagent.
The patients were seen in the clinic every two weeks initially and every one month thereafter.
They wcie asked to report any physical problems immediately to clinic and they arc recorded.
Medications continued for one year and they were asked to undergo cellular phenolypinu
at 9th month and a few patients after 12 months. Western blot of the patients were repealed after
12 months.
Results
The evaluation ot 11 patients for the effect of medication for HIV and AIDS are given in
Tables given below.
Body Weight
In most cases the body weight was positively increased during the first six months. (Iable2)
There after the body weight was found to remain same or showed a slight decrease which may be
due to the increased activity of the patient as they are professional workers. A few cases where
the body weight was decreased drastically (P6) was due to the decreased food intake.
I
I
I
TABLE 2
EFFECT OF MEDICATION ON BODY WEIGHT OF PATIENTS
Name
Before
PI
~50 Kg
P2
P3
P4
3 Months
6 Months
9 Months
54
55
65 Kg
50
53
60 Kg
40
59 Kg
46
44
46.5
43
P5
45
48
47
47
P6
50
41
40
P8
P10
57
50
59
PH
38
51
41
59
65
60
42
49
P7
P9
43
53
36
68
62
47
68
63
45
r
Life Span
.
•
■
.
'
f/,
.
Medication improved the life span of the patients considerably. Patient like P/11 in tact
was discharged from the Medical college Hospital without further treatment. Even this patient
showed positive improvement during the medication.
Two of the patients died (P4 & P7) during the project period. P4 died of acute diarrhoea
and siocmuch candidiasis, and decreased food intake while P7 died of stomach candidiasis. In
fact upon administration of antifungals to this patient at this stage worsened die condition of the
patienl.
Lymphocytes
Total lymphocytes (emm) was normal in all the patients expect P4 which was 690. (Table3) The value did not alter significantly change after the treatment.
TABLE 3
EFFECT OF MEDICINES ON LYMPHOCYTES
I
Patienl
Age
Lymphocytes (emm)
Before
After (I Year)
Pl
P2
P3
P4
P5
P6
P7
42
22
29
29
32
30
28
31
25
30
38
610
4170
3310
690
4500
4500
3810
1750
1450
2810
2830
P8
P9
PIO
■ PH
Normal > 1500 emm
2716
2070
1920
(expired)
1500
sick
(expired)
(discontinued)
sick
1650
3350
CD*i CD*f9 Lymphocytes
CD+a (Total T + B) were almost normal in most of the patients except P4. and the values
were found to be increased after the treatment period. (Table 4)
TABLE 4
EFFECT OF MEDICATION ON T AND B LYMPHOCYTES
Name
cd;
cd;,
_____ Before
1100
3590
2610
380
3550
2017
2970
770
750
2130
2180
Pl
P2
P3
P4
P5
P6
P7
P8
P9
PIO
PH
Normal range CD4, cells/cmm > 1200
180
130
430
90
300
442
270
90
370
230
110
~
cd;
cd7 19
_____After
I 793
1660
1210
291
170
461
930
60
930
2180
180
200
~~
CD+)9 cells/cm 250-750
But B cells count (CD+|9) was found to be low in many patients and in case P2 and P22 B
cell count was fond to be increased after treatment.
CD+7 and CD^ lymphocytes
CD+4 lyphocytes was found to be low in most of the patients and it was well below normal
m P4, PI, P6, P8 and P9. Table 5. The ratio ofCD+4 and CD; was 0.1 - 0.2 in all the patients.
Administration ol medicine increased lhe CD; in most of the evaluated cases with subsequent
improvement in CD4, and CD+ ratio.
■*
X
Percent of CI)+4 in lymphocytes
1 here was an increased in lhe ralio of CD+4 in lymphocytes in several patients after treatment
which at limes was almost similar to normal. (Table 6).
TABLE 5
EFFECT OF MEDICATION ON CD4, CDS CELLS
Patient
CD+4/cmm
CD+x/cmm
Ratio
CD+4/cmm
Before
CD^/emm
Ratio
(after)
PI
100
980
0.1
163
1521
0.10
P2
290
3290
0.1
290
1125
0.25
P3
200
2380
0.1
326
787
0/11
P4
100
280
0.4
P5
300
3200
0.1
240
690
0.34
P6
50
1953
0.1
60
310
0.02
P7
270
2700
0.1
P8
110
600
0.2
P9
120
640
0.2
PIO
290
1840
0.2
130
790
0.2
PH
200
1970
0.1
200
1850
0.1
Normal range CD+4 - 500 - 1500
CD+o - 277 - 1728
TABLE 6
EFFECT OF MEDICATION ON CD4/LYMPHOCYTES RATIO
Patient
CD+4 cells
lymphocytes
% cd+4
CD+4 cells
Lymphocytes % CDHa
163
^90
(after)
2716
2070
6.6
326
240
1920
1500
2810
10.3
130
1650
7.8
2830
7.0
200
3150
6.3
Before
Pl
100
1610
6.2
P2
290
4170
4.8
P3
200
3310
6.0
P5
300
4500
P10
290
PH
200
6.0
14.0
16.9
16.0
CD+4 normal range 500-1500
(Ccils/cmm)
NK cell and activated T cells
NK cell and activated T cell indicate the state of infection. NK cell was very high in P6 and
activated T cell in P4. Both of them became sick later and P4 expired. Increased activated T cell
in P2 was found to be decreased after medication. (Table 7)
Western Blot Analysis
Western Blot analysis of the patients before and after treatment did not significantly produce
any change,and all patients were sero positive after the treatment period.
TABLE 7
EFFECT OF MEDICATION ON NK CELL & ACTIVATED T CELL (DR+) CELLS
Patient
Activated T (DR+)
NKcell
Activated T cell
NK cell
(before)
(after)
Pl
433
110
435
1439
P2
420
790
230
190
P3
170
170
192
442
T4
210
790
P5
590
150
345
555
P6
P7
293
P8
P9
1980
530
850
250
P10
440
150
550
310
PH
530
250
900
Normal range - NK cells - 200-750; Activated T cells 50-300
180
190
50
90
TABLE 8
EFFECT OF AYURVEDIC DRUGS ON HIV-INF^CTED-SYMPTOMATIC
RELIEF
(Total patients -10)
Symptoms
Fever
Diarrhoea
Lymphadcnopalhy
Joint pain
Itchimg
Glossitis
Tuberculosis
Penis ulcer
Disturbed sleep
Cough
Loss of appetite
Headache
Throat Pain
Herpes xoaster
Weight loss
No. of cases
with Symptoms
7
5
2
2
2
5
5
I
4
2
5
I
1
1
10
Relief
Complete
87 (100%)
4 (80%)
1 (50%)
2(100%)
2(100%)
2 (40%)
2 (40%)
No Relief
Partial
1 (20%)
1 (50%)
3 (60%)
3 (60%)
1 (100%)
4 (100%)
1 (50%)
1 (50%)
5(100%)
1 (J 00%)
1 (100%)
1 (100%)
Weight gain 7 Weight mainlained-2
Weight loss I
I
7
In summary, medication was found to be useful in improving the immunological status in
many HIV patients with ARC with subsequent improvement in health. This could be seen from
their weight gain. CD+4 count and other immunological parameters discussed above. Drug also
improved the life span in many patients. However the following observation were also made.
Other general observation
i
1.
The financial status of many patients were very bad and a proper nutritious food along with
medication could have improved the status better.
2.
Many patients have to work hard in order to make their living in spite of the disease. This
might have adversely affected the usefulness of the medication which advocates more rest
to the sick patients.
3.
Oral and stomach candidiasis may product lot of harm to the patient as they arc not be able
to swallow food and medicine. This needed to be taken care of properly.
4.
Patients with TB need take anti-TB drugs.
3)1S X/V. 2_
Value-based University Pogrammes of Study
on HIV and Family Education
Prof. Gracious Thomas
Director, S.O.C.E., IGNOU, New Delhi-110 068
The Indira Gandhi National Open University (IGNOU) is the largest Open
University in the World today with an annual enrollment of over three hundred,
thousand, (300,000) students and over one million students on role. The University has a
wide network not only within the country, but also in as many as 23 other countries. It is
offering 80 programmes and has been declared as ‘Centre of Excellence’ by the
Commonwealth of Learning. Among the nearly 300 Universities and Deemed to be
Universities in India, IGNOU is the first and the only university in the country offering
programmes of study in the area of HIV/AIDS currently.
The Catholic Bishops Conference of India (CBCI) and the Indira Gandhi
National Open University (IGNOU) signed a Memorandum of Understanding (MoU) on
February 29, 2000 and established the IGNOU-CBCI Chair on‘‘Health and Social
Welfare’ at IGNOU.
One of the objectives of establishing this Chair was to develop and launch
programmes of study in the areas of HIV/AIDS and Family Education to address the
unabated spread of HIV/AIDS in the country. This much needed and timely intervention
of the Health Commission of the CBCI saw the launching of the first programme namely;
‘‘Certificate in HIV and Family Education” of 6 months duration from January 2002.
Within one year (in January 2003) the Chair also developed and launched a one year
Diploma on “HIV and Family Education”.
The main target groups for these programmes are the school teachers, NGO
functionaries, para-medicals and parents of adolescents. Already over 2000 students are
enrolled in these programmes.
Among the Indians, sexual norms are still to abide by the life-long rule of
monogamy, while, in most societies severely hit by the FHV/AIDS epidemic, the norms
have been ‘change of partners’. Virginity before marriage is still highly valued among
most Indians and families have by and large greater control over the behaviors of children
at least until they are married and settled.
However, with India’s shift from a predominantly agricultural, low subsistence
and low consumption economy and a community based social structure, to an industrially
developing nation with urbanization, globalization, migration and break down of rural
economies, joint family system and communities, there have been shifts in social values
and world views. The degree and nature of this impact has been various across different
sections. The weakening controls have allowed greater individual freedom and releasing
the stifling controls on young people. Much of the publicity materials used in HIV/AIDS
awareness in India are copied from literature prepared in foreign countries meant for a
1
f
1
society having different cultural setting. There is much resistance from school teachers
and parents in using these materials in schools and in training program for various target
groups in India.
Considering the need of the society, CBCI-IGNOU Chair on ‘Health and Social
Welfare’ has developed a set of academically sound and socially acceptable quality
materials-print, audio and video-which form part of the educational package. These are
value based materials prepared keeping in view the social, cultural, family, religions and
moral values dear to the Indian Society. The seven courses which form part of the
Certificate and Diploma programmes are:
- Basics on HIV/AIDS (4 credits)
- Elective on HIV/AIDS (4 credits)
- Basics of Family Education (4 credits)
- Elective on Family Education (4 credits)
- Alcohol, Drugs and HIV (4 credits)
- Communication and Counselling in HIV (4 credits)
- Project Work (8 credits)
Anyone with a 10 + 2 qualification from any part of India can enroll for these
programmes. The University has kept the fee very low in order to make this programme
accessible to almost anyone interested. For a certificate one needs to pay Rs. 800/- while
for the Diploma the fee is Rs. 1600/- inclusive of examination fee, registration fee as well
as the print package. These programmes are available both in English and Hindi.
The humble beginning that the CBCI initiated in collaboration with IGNOU to
prevent and control HIV/AIDS has attracted people from various walks of life. Today
over two thousand learners from all over country are doing these programmes through
distance learning mode. It is a matter of satisfaction to report that these value based
programmes have attracted world attention. Already the Kenyatha University from Kenya
has sought license to adapt this value based programme in that country. IGNOU has also
started offering these programmes in Namibia. Apart from these formal programmes of
study, this small initiative of the Church has motivated IGNOU to use other strategies to
reach out to millions across the country with HIV/AIDS prevention messages.
Currently IGNOU is involved in a massive HIV/AIDS Awareness Campaign all
over the country. As a part of the campaign the University is reaching out to all its
students through an HIV/AIDS folder: ‘HIV Prevention Guide’ for students which is
being mailed to over 300,000 fresh students and its readership every year is estimated to
be over one million. Apart from this IGNOU has produced over a dozen video films and
audio programmes which are being telecast/broadcast over Doordarshan/Gyan Darshan
and All India Radio as well as Gyanvani. Besides this, IGNOU also regularly conduct
teleconferencing as well as interactive radio counseling on this subject. Above all the
University also conducts awareness/publicity seminar in various states through IGNOU
Regional Centres located in state capitals.
2
HIV/AIDS’ Patient and His or Her Rights
P.D. Mathew S.J.
Indian Social Institute, Delhi
HIV/ A TPS is the most dangerous disease the world faces today. There is no
certainty about the origin of this disease, however, it is believed that its virus first surfaced
in Africa. Later, somehow it moved to the United States, where it was first detected
decades later .After its first detection, the Disease has remained in existence for more than
twentv years now, without a foolproof medical response in terms of vaccination against it
or its cure The Disease, in absence of effective and easily available/accessible treatment
troubles not onlv the individual sufferer but also society at large. The number of patients
suffering from this disease is quite daunting. The total number of HIV-positive people in
the worid rose from 10 million in 1990 to 28 million in 1996, 34 million in 2000, and to as
many as 40 million in 2002.
There are several dimensions of the Disease including moral and legal. The legal
dimension of this Disease is about at least three basic questions. First, what are the rights
of the patient suffering from HIV/AIDS'’ Secondly, what are the rights of people in general
to protect and prevent themselves from being affected by the Disease? Thirdly, what are
the duties of various stakeholders, patients, public and the State’
The present article discusses some important rights of patients suffering from the
Disease. These are the Right to Privacy, the Right to xMarry and the Right to Employment.
In order to trace these rights, the provisions of various relevant international instruments,
the provisions of the Indian Constitution and some judicial pronouncements are considered
in the article.
There are several instances of cruel and inhuman treatment meted out by society to
the HIV/AIDS patients on grounds of morality etc. The Law, however, has no such
provisions permitting discriminatory, inhuman, degrading or cruel behaviour against them.
Though suffering from this dangerous disease, the patients have certain rights provided for
by different instruments at the international as well as domestic level. There has also been
an attempt to clear some ambiguity pertaining to these rights through judicial
pronouncements.
(i) Right to Privacy
Some of the fundamental provisions entailing the right to privacy are as under.
The Universal Declaration of Human Rights (UDHR) Article 12:
1
No one shall be subjected to arbitrary interference with his privacy, family, home
or correspondence, or to attack upon his honour and reputation. Everyone has the
right to the protection of the law against such interference or attacks.
The International Covenant on Civil and Political Rights (1CCPR) Article 17:
1. No one shall be subjected to arbitrary or unlawful interference with his privacy,
family, home or correspondence, or to unlawful attacks on his honour and
reputation.
2. Everyone has the right to the protection of the law against such interference or
attacks.
Similarly, the Constitution of India provides for the Right to Life under Article 21.
Which means the right to a decent and dignified life including the right to privacy. As is
the case, rights are always subject to certain conditions. The exercise of various rights
within the purview of the Right to Life under Article 21 of the Constitution is also subject
to certain conditions like public health, safety, public order, public interest etc.
A difficult situation arises when a patient asserts his/her ■ right to privacy or
confidentiality and it comes in conflict with the question of public health, order, safety etc.
In the event of such a conflict the Roman Law principle, ‘Sains populi est suprema
(resard for the public welfare is the highest law) should apply. In Mohan Patnaik v.
Government ofA.P., I Andh LT 504, it was held that in case of conflict between individual
fundamental rights and larger interest of the society, the latter right would prevail. The
Supreme Counof India, in Nir.
v. Hospital ‘Y’, AIR 1999 SC 495, held that Article 21
includes right to privacy, but the same is not absolute. The Court further said that
disclosure by Doctor that patient who was to get married has tested HIV+ve, is not
violative of patient’s right to privacy.
The position of the right to privacy, therefore, is as follows:
(1) Everyone, including the HIV/AIDS patient, has the right to privacy.
(2) Such a right may be curtailed in the larger public interest.
(ii) Right to Marry
The Right to Marry is another fundamental right which every human being has.
The Universal Declaration of Human Rights providing for this right states in Article 16
(1):
Men and women of full age, without any limitation due to race, nationality or
religion, have the right to marry and to found a family. They are entitled to equal
rights as to marriage, during marriage and its dissolution.
Also, this right finds a place in the International Covenant on Civil and Political
Rights. Article 23 (2) of the Covenant provides:
2
The right of men and women of marriageable age to marry and to found a family
shall be recognised.
The Rioht to Marry is inherent in the Right to Life as provided for in the Article 21
of the Constitution of India. However, the Supreme Court made it clear that it is not an
absolute right. Person suffering from venereal disease has a suspended right to marry till he
is cured of the disease. The Court held:
The emphasis, therefore, in practically all systems of marriage is on a healthy body
with moral ethics. Once the law provides the '‘venereal disease" as a ground for
divorce to either husband or wife, such a person who was suffering from that
disease, even prior to the marriage cannot be said to have any right to marry so long
as he is not fully cured of the disease. If the disease, with which he was suffering,
would constitute a valid ground for divorce, was conceaded by him and he entered
into marital ties with a woman who did not know that the person with whom she
was being married was suffering from a virulent venereal disease, that person must
be injuncted from entering into marital ties so as to prevent him from spoiling the
health and, consequently, the life of an innocent woman. (Mr. ‘X’ v. Hospital Z ,
.MR 1999 SC 495).
In the same case, dwelling on the right of a person to lead a healthy life, and therefore to be
informed of the health condition of his/her prospective spouse, the Court further held:
As a human being, Ms. Y must also enjoy, as she, obviously, is entitled to, all the
Human Rights available to any other human being. This is apart from, and, m
addition toffhe Fundamental Rights available to her under Article 21, which, as we
have seen,’guarantees “Right to Life” to every citizen of this country. This right
would positively include the right to be told that a person, with whom she was
proposed to be married, was a victim of a deadly disease, which was sexually
communicable. Since “Right to Life" includes right to lead a healthy life so as to
enjoy all faculties of the human body in their prime condition, the respondents, by
their disclosure that the appellant was HIV(+), cannot be said to have, in any way,
either violated the rule of confidentiality or the right of privacy.
Moreover, where there is a clash of two Fundamental Rights, as in the instant case,
namely the appellant’s right to privacy as part of right to life and and Ms. ‘Y’s’
right to lead a healthy life which is her Fundamental Right under Article 21, the
RIGHT which would advance the public morality or public interest, would alone be
enforced through the process of Court, for the reason that moral consideartions
cannot be kept at bay and the Judges are not expected to sit as mute spectators of
clay in the Hall, known as Court Room, but have to be sensitive, “in the sense that
they must keep their fingers firmly upon the pulse of the accepted morality of the
day.”
Further, the Court, considering Sections 269 and 270 of the Indian Penal Code, held that
these statutory provisions impose a duty upon the appellant not to marry as the marriage
would have the effect of spreading the infection of his own disease, which obviously is
dangerous to life, to the woman whom he marries. The said Sections provide:
“269. Negligent act likely to spread infection of disease dangerous to life - Whoeve
unlawfully or negligently does any act which is, and which he knows or has reason
to believe to be, likely to spread the infection of any disease dangerous to life, shall
be punished with imprisonment of either description for a term which may extend
to six months, or with fine, or with both.
270. Malignant act likely to spread infection of disease dangerous to life k
Whoever malignantly does any act which is, and which he knows or has reason to
believe to be likely to spread the infection of any disease dangerous to life, shall be
punished with imprisonment of either description for a term which may extend to
two years, or with fine, or with both.”
(iii) The Right to Employment
The Right to Employment is also a very important human right. Some provisions
pertaining to this right which form a part of the International Bill of Human Rights are:
Article 23 (1) of the Universal Declaration of Human Rights -
Everyone has the right to work, to free choice of employment, to just and
favourable conditions of work and to protection against unemployment.
Article 6 (1) of the International Covenant on Economic, Social and Cultural Rights
The States Parties to the present Covenant recognise the right to work, which
includes the right of everyone to the opportunity to gain his living by work which
he freely chooses or accepts, and will take appropriate steps to safeguard this right.
The Constitution of India, in its chapter on the Directive Principles of State Policy, directs
the State to make effective provision for securing the right to work. The chapter on
Fundamental Rights provides for non-discrimination with regard to opportunity in public
employment. The Constitutional provisions to this effect are:
Article 16 (1). There shall be equality of opportunity for all citizens in matters relating to
employment or appointment to any office under the State.
Article 16 (2). No citizen shall, on grounds only of religion, race, caste, sex, descent, place
of birth, residence or any of them, be ineligible for, or discriminated against in respect of,
any employment or office under the State.”
The Bombay High Court, in ATT of Bombay Indian Inhabitant v. M's. Z.Y, AIR 1997
Bombay 406, addressing a question as to whether it is permissible for the State under our
4
Constitution to condemn a person infected with HIV to virtual economic death by denying
him employment, held:
“... The rule providing that person must be medically fit before he is employed or
to be continued while in employment is, obviously, with the object of ensuring that
the person is capable of performing his normal job requirements and that he does
not pose a threat or health hazard to the persons or property at the work place. The
persons who are rendered incapable, due to the ailment, to perform their normal job
functions or who pose a risk to the other persons at the work place, say like due to
having infected with some contagious disease which can be transmitted through the
normal activities at the work place, can be reasonably and justifiably denied
employment or discontinued from the employment inasmuch as such classification
has an intelligible differentia which has clear nexus with the object to be achieved,
viz., to ensure the capacity of such persons to perform normal job functions as also
to safeguard the interests of other persons at the workplace. But the person who,
though has some ailment, does not cease to be capable of performing the normal
job functions and who does not pose any threat to the interests of other personsat
the work place during his normal activities cannot be included in the aforesaid
class. Such inclusion in the said class merely on the ground of having an ailment is,
obviously, arbitrary and unreasonable. ... the impugned rule which denies
employment to the HIV infected person merely on the ground of his HIV status
irrespective of his ability to perform the job requirements and irrespective of the
fact that he does not pose any threat to others at the work place is clearly arbitrary
and unreasonable and infringes the wholesome requirement of Article 14 as well as
Article 21 of the Constitution of India.”
The Supreme Court of India, in Mr. ‘X’ v. Hospital CY’ AIR 1999 SC 495, held:
The patients suffering from the dreadful disease “AIDS” deserve full sympathy.
They are entitled to all respects as human beings. Their society cannot, and should
not be avoided, which otherwise, would have bad psychological impact upon them.
They have to have their avocation. Government jobs or service cannot be denied to
them as has been laid down in some American decisions.
Subject to certain reasonable restrictions, which are expedient in the larger public interest,
the HIV/AIDS patient has all the rights. These include the right to life, the right to health,
the right to education, the right to freedom of expression, the right to movement, the right
to equality etc. Merely on the ground that a particular person is suffering from HIV/AIDS,
he/she cannot be denied any of the rights available to human beings.
5
HIV/AIDS in India - Church’s Responsibility
DR. G.D. RAVINDRAN
ST. JOHN'S MEDICAL COLLEGE HOSPITAL
BANGALORE
Introduction:
The first case of HIV was detected in India in 1987. In the last 15 years, the
eoidemic has soread rapidly all over the country. Today India has about 4 million
HIV positive people. If this trend continues, India will be the leading country with
HIV infection in the world in the near future.
Impact ofHIV AJDS
HIV/AIDS increases the mortality and morbidity rates of the affected communities.
It will increase the infant and under five mortality. The'number of orphans will
increase. It also produces emotional trauma and discrimination among the infected
individuals.
HIV/AIDS also has an economic impact. The work force of the country will be
affected as youna adults are affected. National budget on Health care is likely to
increase as the demand for care of HIV infected
individuaTs increases. It is likely
that the country will loose all the economic gains that it has achieved and slide
back in development. Poverty worsens inequality and increases human rights
abuses.
Trends in HIV spread:
89% of infections occur among the sexually active and economically productive
age group of 18-40 years. 25% of HIV positive patients are women. The disease
has not spared children. The virus infects about 30,000 newborn children. At least
120,000 children rendered orphans by the epidemic.
There are certain differences between the epidemic in India and in the Western
world. The HIV virus seen in India belongs to clade type C, in the west it is clade
-r’vTJTTb.------
B. In contrast to the West, heterosexual transmission is the commonest mode of
infection. Incidence of HIV associated with blood transfusions is decreasing. The
incidence of HIV transmission from Mother to cliild is increasing in the country.
Intravenous drug abusers are one of the sources of HIV transmission in the
Northeastern regions of the country. From being, a disease of the urban areas and
of groups that indulged in high-risk behaviours it has now become a disease that is
seen among the rural areas as well as the general population
Factors that Influence the spread of the disease in India:
The behaviour of people puts them at the risk for developing disease. General
awareness of the disease and its mode of spread are .low in the community'.
Incidence of reproductive tract infections as well as sexually transmitted disease is
hidi. Changing social behaviours patterns due to the influence of the media and the
peer pressures leads to risky sexual behaviour.
Gender inequality and poverty also contribute to the spread of the infection. Large
population of migrant workers tend to have high-risk behaviour when they are
away from their famihes. Economic necessity and gender inequality render sex
workers vulnerable to acquire the infection. In the Northeastern regions of our
country intravenous drug abuse also contributes. In a study conducted by
NIMHANS at Bangalore, alcohol abuse was one of the factors that increased the
risk for acquiring the infection.
Abuse of blood and blood products as well as unsafe blood banking practices also
contributes. Similarly, poor antenatal facilities also contribute to spread of
infection.
Efforts by the Government to combat the spread of the infection in India:
Governmental efforts in prevention
With the advent of the infection, the central Government set up a National AIDS
Committee in 1986 and launched the National AIDS control programme in 1987.
In 1992, the Government formulated a new programme and changed the committee
into a National AIDS control organisation (NACO). It also formulated a policy that
involved a multi sectoral approach and with the involvement of Non-governmental
organisations (NGO) to control HIV/AIDS in the country.
NACO implements its policies as well as its activities through the different State
AIDS Cells/societies in the states. Its activities involve programme management,
surveillance, research, information, education and counselling activities. It also
undertakes initiatives to ensure safe use of blood, reduction of Sexually transmitted
disease (STD’s), condom promotion and undertakes interventions that can reduce
the impact of the disease.
Efforts bv the Catholic Institutions:
The Catholic Hospital Association formulated an HIV/AIDS policy in 1997. It has
been conducting various training programmes and interventions through its
members. Catholic hospitals have been in the forefront of providing care for the
HIV/AIDS patients in the country. Catholic colleges have actively taken part in the
University programmes on AIDS control. Some schools have made HIV/AIDS
classes as part of the curriculum. These efforts have not been coordinated and
consistent to have an impact on the epidemic in the country.
Preventive measures and Catholic Institutions role:
Measures to prevent the spread of HIV involve both medical as well as social
interventions.
Combination
preventive
strategies
that
involve
multiple
interventions that work synergistically will reduce the incidence of the disease.
Hence, there is a need to have inter sectoral collaboration within the church.
Medical interventions
Medical interventions like voluntary testing and counselling will increase the
awareness of the need to reduce high-risk behaviour as well as bring the disease
into open. Catholic hospitals with their holistic approach to health care are in a
better position to implement this intervention. There is a need to strengthen
personnel in the hospital by conducting training programmes.
Provision of safe blood transfusions has reduced the incidence of HIV transmission
through this route. Implementation of strict laws by the Government has ensured
this achievement. Catholic Hospitals working in rural areas may not have access to
a safe blood transfusion. We need to look at this problem pragmatically and find
solutions.
Providing treatment for opportunistic infections as well as for the HIV patients in
the institutions will reduce the stigma as well as provide care for the patients.
Though catholic Hospitals are doing a wonderful job on this front, there are still
some institutions that do not provide care. The major hurdle has been the attitude
of the staff. To change this attitude, there is a need to provide training programmes
for all categories of the staff. The administration also needs to be strict to combat
the attitude.
Control of sexually transmitted disease by prompt treatment of STDs can lead to
risk reduction. Prompt reporting of the cases to the governmental authorities will
ensure better statistics as well implementations of preventive measures in the
community.
Catholic hospitals are renowned for Mother and Child health services. We should
build on these strengths. Provision of HIV counselling, testing antenatal mothers
and providing antiretroviral therapy will definitely reduce the transmission as well
as the impact of the disease. There is an urgent need to explore this intervention so
that we can make a definite dent on the disease.
Programmes that reduce alcohol as well as intravenous drug addiction will
definitely make an impact. Many hospitals have de-addiction programmes in place.
Provision of needle exchange programme in these de-addiction programmes will
go a long way in reducing the spread of the disease.
Provision of universal precaution and safe disposal of wastes will not only protect
our staff but also help the environment.
Social Interventions
Social interventions involve general interventions as well as interventions that
target specific vulnerable groups in the community. Knowledge is power and an
individual should have the knowledge about the disease so that she can protect
herself. Our educational institutions can play a vital role. The knowledge about
HTV/ATDS should be incorporated in the school curriculum. It must begin in lower
classes (3rd or 4th STD) and the content must be increased gradually. The theme in
the lower classes must be that we have to protect our body against all sorts of
harm. In the higher classes, sex education should be made a part of the curriculum.
To implement this type of curriculum, teachers need to be trained to handle issues
with sensitivity. Colleges can introduce seminars and awareness programmes.
At the parish level, youth groups can take up awareness programmes. To reduce
the stigma as well as increase awareness churches can celebrate an ‘AIDS day’.
Awareness of HIV and its prevention should be a part of every marriage
counselling. Family education and support services need to be strengthened at the
parish level.
Social welfare schemes that are run by the church can help to reduce the spread of
the disease. Increasing the economic capacity and local employment can prevent
migrations. These schemes can also be used to spread awareness in the community.
Targeted intervention programmes may be a little difficult to implement by the
church institutions. There are groups that work in the prisons, among street
children and among marginalised people. They can have AIDS prevention
activities.
Working with certain high risk groups can lead to moral and ethical dilemmas in
catholic institutions e.g. AIDS prevention work among sex workers. We are
comfortable in providing rehabilitative measures for sex workers but AIDS
prevention has to be conducted with active sex workers. Similarly, dilemmas arise
when working with drug addicts and gay men. We need guidance from the church
authorities.
Impediments to effective prevention work:
The attitude of the institutions is a major impediment for implementing AIDS
awareness programmes. That needs changing. We need training programmes to
train health personnel as well as teachers. Institutions that can offer this type of
training need to be identified.
Drugs are essential to prevent mother to child transmission as well as to treat HIV
infected patients. Intervention programmes need dedicated staff and there must be
provisions to provide for salaries. All of these need money.
The church institutions get support form internal resources. Huge amounts are
available through external funding for AIDS awareness programmes. Institutions
need to tap these resources. Catholic institutions do not tap Governmental
resources. We should shed our inhibitions and approach the government for
fimding. We need a resource centre that can help our institutions to write good
proposals. This centre should also inform institutions about the sources of funding
that are available.
Ethical dilemmas that arise in the course of AIDS awareness programmes need to
be addressed. At present, people grapple with these dilemmas privately as well as
approach local resources. We need a body that will address these issues from an all
India perspective. The CBCI should take an initiative in this regard.
Advocacy has been one of the important aspects of HIV/AIDS epidemic. Bringing
Human rights abuses to notice as well as empowering the marginalised members of
the society needs a powerful advocacy at all levels. Church with its social
organisations is eminently suited to take up these issues.
In the states that have a high prevalence of HIV a large number of catholic
institutions are present. Catholic institutions can definitely make an impact on the
HIV epidemic in India.
Atojit: MlV/AlDs
NACP
Speeches of PM/MOH Indian Scenario
o rg an EXTON profile Global Scenario
Ask the Doctor-
Sits Map
Announcements
Related Sites
Letter from Pro.Dir SACS
4?
HIV/AIDS Indian Scenario
HIV/AIDS Surveillance in India
(as reported to NACO)
As on 30th June, 2003
AIDS CASES IN INDIA
Cumulative
This Month
MALESi
39466
329
FEMALES
13705
87
'7J" 53171
416
Total
RISKHRANSMISSION CATEGORIES
'
Sexual
45435
85.45
Pennatai transmission
1455
: 7 2 74
Blood and blood products
1409
2.65
■
Injectable Dmq Users
■
1309
1
2.46
History not available
3553
670
Total:
53171
100.06
0 -14 yrs
1252
777
2029 ;
15-20 yrs.
12231
6289
18520
30 -44 yrs
22957
5880
28837
>45 yrs.
3026
759
:
3785
1
Andhra Pradesh
2
Assam
::: 3
.. .■
3707
/
;
■.. Arunaehal Pradesh ,:•
:g:<Jg|^|||i|:J
. iggi
A & N islands /..
4 :
27
6
Chandigarh (UT)::: 'i .:
733
•
7
Delhi
807
:
8
Daman & Diu
9
Dadra & Nagar Haveli
10
Goa
11
. Gujarat
12
Haryana
< 266°
<<:271 ■'
13
Himachal Pradesh
'■<
14
Jammu & Kashmir
15
Karnataka
IS
Kerala
0
194
<
112
2
;
.'
1707
267
Lakshadweep
: 17
g 18g< Madhya Pradesh
'9
.
g:|g|:
152
5
•
1:71 •.■■<-
Maharashtra
998
9234
20 Ls Orissa ■:
. 82
21
Nagaland
331
22
Manipur
1238
23
Mizoram
< : 50 ■
24
Meghalaya
25
Pondicherry :
26
Punjab
27
Rajasthan
751
Sikkim
8
8 ,::
157
^:<-;243
W.V.VAV.VASSWtW.W
L 23
Tamifnaduggilg
29 :
24667
SV.WAWAM.W’.WA’AS
.■AWW.WAWSV.
30
Tripura
31
Uttar Pradesh
6
9S3
32
West Bengal
930
33
■ Ahmedabad M.C
267
34
Mumbai M.C
....... .................. < 2404 <«:'
^^^53171'^1
T)is
HIV/AIDS: ETHICAL RESPONSE OF THE CHURCH
Thomas P. Kalam, CMI, St. John's National Academy of Health Sciences, Bangalore
1, Christ's View of Illness: Basis for Christian Ethical Response to HIV/AIDS
Christ's view on illness as expressed in two loci in St. John's Gospel can form the
basis for a Christian ethics of HIV/AIDS:
John 11:4: "This illness does not lead to death; rather it is for God's glory, so
that the Son of God may be glorified through it;" and,
John 9:3: "Neither this man nor his parents sinned; he was born blind so that
God's works might be revealed in him.
In the same vein, HIV/AIDS can be considered from a Christian perspective as, "for
God's glory, so that the Son of God may be glorified through it" and "so that God's
works might be revealed."
The central question should be how God's power and compassion might be seen at
work in this pandemic.
So many millions being HIV positive is a tragedy; so many billions not being positive
about HIV is a greater tragedy.
It was St. Iranaeus who pointed out long ago: "The glory of God is a human being
who is fully human and fully alive." The human being seems to be God's proudest
boast in the whole of creation. HIV/AIDS seems to be yet another occasion and call
to live the human to its fullest possible realisation.
It is in this context that one must appreciate the response that the Church gave to
the HIV/AIDS pandemic by helping to institute a Chair at IGNOU for "Family Life
Education" in the context of HIV/AIDS. The Health Commission of CBCI and Dr
Gracious Thomas of IGNOU deserve the all the appreciation for this wonderful
gesture.
2. Ethics of HIV/AIDS: Casuistry vs. Life affirminfl
Ethics of HIV/AIDS cannot afford to be confined to casuistry, though as Enda
McDonagh rightly points out that it is a useful instrument in detailing Christian moral
response to a range of difficulties.
■
■
■
Clean needles for recovering drug addicts
condom for protecting the non-infected partner
obtaining consent before testing for HIV/AIDS, the right to refuse
■
■
treatment
Physician's duty to treat HIV/AIDS patients
Patient's right to confidentiality with regard to HIV status
may all be important issues that must be addressed. They however should not be
allowed to dominate the ethics of HIV/AIDS.
Ethics as the science of what a human being ought to be on the basis of what
he/she is (Marc Oraison) promotes the art of living the fullness of human life.
Ethics of HIV/AIDS must be developed with reference to this ultimate aim of
achieving the fullness of life and thus the glory of God. All those principles, which
enable people who live with HIV/AIDS and all others to achieve greater fullness of
life, should form the ethics of HIV/AIDS. Therefore HIV/AIDS must be considered as
v
a "moral booster!" For,
human life:
HIV/AIDS touches all the important existential variables of
(1980; "Afterword- AIDS: An American Epidemic," added to 1986 ed.)
3.
HIV/AIDS: not God's Punishment for Sin
' •
i Christian ethics of HIV/AIDS, one conjecture that must
In our effort to formulate a
ruled out at the very outset is the view that HIV/AIDS was sent by God to punish
be flUIV-'-a KZ V. V —
- —- /
.
people for their• violations
violations of
of Christian
Christian moral
moral values.
values, This theological conjecture
seems to be
be blatantly
blatantly unscientific,
unscientific, blasphemous
blasphemous and self-righteous. Unsc,e^c'
seems
y
....
------- ( j------ was at the source of HIV
because there is no decisive proof that any moral depravity
being introduced to human organism. This virus can be
L, transmitted in different
epidemiological
issue
rather
ways, moral, immoral and amoral. It is primarily an lr
NA7arpth
..y '
moral one
Blasphemous, because, the God whom Jesus of Nazareth
revealed is a God of mercy and compassion, not of condemnation. His mam 'nterest
lies in the conversion and healing of human beings and not in their destruction and
punishment. The God whom Jesus reveals is diametrically the opposite to such a Go
of vindictiveness. Sadly such a revengeful God is still presented at times under the
guise of the 'Good News' preached by the Catholic Church. As Kevin . e y say
"We cannot present such a God of condemnation and then dare to claim This is the
Gospel of the Lord'." Self-righteous, because it is doubtful that all who are not
infected with this virus can honestly claim that they have been upholding the
Christian values they would like to assume that those HIV pos.tive human‘
have supposedly violated. Moreover, it is a fact that many people living with AIDS
can be more accurately described as the victims of the injustice and oppression of
others rather than as people whose immoral life-style has brought this trage y upon
SXXs (e g women a'nd children). The most despicable sin that Jesus abhors in
the pages of the Gospels is not adultery or prostitution; it is self-righteousness.
blamed for lack of enthusiasm in these preventive and
The Church has been
especially because of moralisation due to the
educative measures regarding AIDS
violations of the moral teaching of the
prejudice at the initial stage that it was the
Church that brought about this scourge. "The slow-witted approach to the HIV
of Christian malpractice and the
epidemic was the result of a thousand years
childlike approach of the Church to sexuality, wrote Derek Jarman, British
in his At Your Own Risk: A Saint's Testament, 1980 s
filmmaker, artist, author, i
- ..
(1992).
The society at large has been blamed of politicisation of this disease, and the efforts
at prevention and education have become handicapped through this politicisatio .
As Dennis Altman Australian sociologist wrote: "Both the Moral Majority, who are
mcycHng meSva language to explain AIDS, and those ultra-leftists who attribu e
AID osome sort of conspiracy, have a clearly political analysis of the epdemic.Bu
even “one attributes its cause to a micro-organism rather than the wrath
Go o
XS iXSISS
thbeS X ^iitica, oh
diseases." AIDS in the Mind of America, Ch. 2 (1986).
It is time that the Church stops moralising HIV/AIDS and sees; it as a human
problem. It is time for the society to de-politicize HIV/AIDS and
<..._ accord it all the
urgency it deserves.
2
4. Different ways
in
which
HIV/AIDS
becomes
an
occasion
for the
promotion of fullness of life:
a.
By celebrating life when it is disrupted by HIV/AIDS: HIV/AIDS
presents a situation the actual nature of fullness of life is related to the
concrete context its ultimate brokenness. This was the message of Calvary
where, when human life was overcome with pain, desperation and
hopelessness, Jesus continued the celebration of life: ""It is completed" (John
19:30). The cross on Calvary remains the symbol of the ultimate hope in a
hopeless human life.
b
in the positive living of people with HIV/AIDS: Often people get healed
through their diseases.
It is true also in the case of HIV/AIDS. At a
conference on AIDS in Bangkok a certain Krishna, comparing 32 years of his
life as HIV negative and 6 years of his life as HIV positive, stated confidently
that it was like night and day: 32 years of night and 6 years of day in his life.
Anthony Perkins, (1932-92), U.S. screen actor made this statement
published posthumously in Independent on Sunday (London, Sept. 20,
human
1992):
"I have learned more about love, selflessness and human
understanding in this great adventure in the world of AIDS than I ever did in
the cut-throat, competitive world in which I spent my life."
To illustrate what it means to 'live positively with HIV/AIDS', let me quote
from a book by Noerine from Uganda entitled IVe Miss You All where she is
explaining its meaning:
"Living positively with AIDS. The public health messages were saying:
"Beware of AIDS. AIDS kills", "You catch it and you are as good as
dead." There were no messages for those people who were already
infected. What was implied was that people who were already infected
should die and get it over. People with HIV and AIDS were seen as
dying. We adopted the slogan of "living positively with AIDS. For us it
was the quality rather than quantity of life which was important. Once
infected with a deadly virus like HIV people need to take definite steps
to enhance the quality of whatever life they have left. They must
develop a positive attitude to life.
Having a positive attitude to life means:
■
■
■
■
■
■
■
■
knowing and accepting that they are infected
knowing and understanding the facts about AIDS
taking steps to protect others from their infection
taking care not to expose themselves to further HIV infection or
other infections
taking special care of their physical health and treating symptoms
of ill health as soon as possible.
having access to emotional support
continued participation in social life
eating well and avoiding or learning to cope with stressful
situations.
This seemingly complex philosophy is attainable. Achieving positive
living is a process, with ups and downs, in which we all need support.
It is part of working through the various feelings that having HIV may
bring: shock, denial, anger, bargaining, acceptance and hope.
Counsellors, carers, and friends should learn to recognise this
instability, and not be frustrated when progression through the stages
3
seems erratic, and we regress to former emotional reactions. We need
to be accompanied through these stages by a sensitive, understanding
friend who pledges to be there for us.
The question is whether as a Church we manage to 'live positively with AIDS.'
The insistence here is on the giftedness and preciousness of time as
appreciated by people who are living positively with AIDS and the deep sense
of responsibility this engenders in them, as well as the desire to live the
present as fully as possible.
c.
In the Cry of those with HIV/AIDS:
The ability to cry for help is part and parcel of a life lived to its fullest.
Life means not only the ability to give, but also the ability to receive
gracefully. It is this cry which bonds together different lives.
Ultimately, whatever is important in the life of a person are those gifts
of life that were freely given to him/her. Human beings' ability to be
open to the Grace that is bursting into life freely is one of the clues of
fullness of life.
d. In the Care given to people living with HIV/AIDS
"One does not live by bread alone" (Matt 4:4). Human beings are
sustained by fulfillment of needs which transcend the mere
physiologial and security needs. People living with HIV/AIDS proclaim
this truth loud and clear:
As Amanda Heggs, AIDS sufferer said: ""Sometimes I have a
terrible feeling that I am dying not from the virus, but from
being untouchable." Quoted in: Guardian (London, 12 June
1989).
Derek Jarman (b. 1942), British filmmaker, artist, author
wrote: "I'm not afraid of death but I am afraid of dying. Pain
can be alleviated by morphine but the pain of social ostracism
Saint's
cannot be taken away.." At Your Own Risk:
-------A --------Testament, "1980's" (1992).
e. in the efforts for positive action for prevention and education!
It is evident that a response to HIV/AIDS in terms of practical charity
demands effective action in the field of prevention and education.
Prevention is not only better than cure, it a pre-emptive cure itself.
Gratitude for the gift of life should not be limited to occasions when
cure of diseases is experienced. Health itself is the most miraculous
healing in life. Preventive measures, including education, are here
seen as part of the ongoing celebration of the fullness of life.
5. Ethical Conflicts regarding HIV/AIDS
Ethical conflicts that arise in dealing with HIV/AIDS can be grouped under three
areas:
1. IN DEALING WITH PEOPLE AFFECTED BY HIV/AIDS:
This ethics should
promote the care and treatment persons affected by HIV/AIDS should get; it
should guarantee strong action to protect individuals against discriminatory
treatment or any form of persecution or ill treatment; it should protect the
dignity of the affected as human beings.
4
2. IN DEALING WITH THE GENERAL PUBLIC NOT AFFECTED: it should positively
address the need to protect public health by helping to promote ways of
preventing the spread of HIV/AIDS.
3. IN DEALING WITH ENHANCEMENT OF QUALITY OF HUMAN LIFE: it should
enable everyone, both the infected and the non-infected to 'live positively'
with this pandemic of HIV/Al DS. The quality of human life should be
enhanced in the way we deal with HIV/AIDS.
In the matter of HIV/AIDS, the poles of ethical conflict are:
Public health
vs. Fundamental rights of an individual;
Utility (for many)
vs. Liberty (for the few).
On the one hand, there is for the affected individual the possibility of discrimination
- of loss of employment or residence, a risk of public shunning, a possibility of
psychological distress acute enough to lead to suicide.
On the other hand there is the concern for public safety: the right of the public to
be protected against the disease.
Therefore, one has to strike a balance which, while protecting public health, will also
protect individuals so that they will feel free to come forward for available
treatment. Any one-sided and divisive approach that sets fundamental rights of
individuals in opposition to public health, or vice versa, or which does not give hope
to both the affected and non-affected cannot be considered as constructively
ethical.
5, 1. Rights of Persons Living with HIV/AIDS to care and treatment:.
Often persons living with HIV/AIDS face difficulty in obtaining access to quality care
and treatment. Some health care professionals refuse to treat persons living with
HIV/AIDS for their HIV-related illnesses; others refuse to treat patients with
HIV/AIDS who consult them in connection with medical problems that are unrelated
to HIV. At times they betray an attitude that HIV-positive persons are just not worth
receiving quality, expensive medical care. Often there are prejudices within the
medical profession, in particular against prostitutes, homosexuals, injection-drug
users, and women.
The ethical questions here are: Do health-care professionals have a duty to treat
patients with HIV/AIDS? Do people affected by HIV/AIDS have a right to have access
to care and treatment?
Generally speaking the doctor has a moral duty to treat all patients, including
patients with HIV/AIDS. This duty comes from the doctor's professional ethics which
obliges a medical practitioner to treat all patients they are competent to help. This
duty is also involved in the oath that every doctor takes at the beginning of his
practice.
People with HIV/AIDS have the same right to health care and respectful treatment as
any other person. The right to health is a fundamental right. HIV/AIDS patients are
in no way excluded from this fundamental right. Health-care providers therefore
have the obligation to provide that care, and it is unethical for any health provider:
(1) To refuse to care for any person who is HIV-positive or who has AIDS, or
(2) To make the care of any person contingent on that person having an HIV test.
Though the physicians have an obligation to treat patients with HIV/AIDS, this
obligation does not seem to be unlimited. There are factors which might limit the
5
obligation. Some of such factors are, for example excessive risks, questionable
benefits, obligations to other patients, or obligations to self and family.
Another important issue is that, while one can assert a duty to treat, one cannot
araue that the medical professionals or the general public have a duty to be not
afraid Similarly, one cannot coerce empathy or any other feelings or attitudes that
are essential to the development of caring relationships between physicians and
patients It should come from an attitudinal change on the part of the health care
P
. Therefore there is a need to stress the importance of education of
professional.
and institutions about:
health-care workers
v
□ how to treat HIV,
□ the risk (or absence thereof) of patient-doctor contact,
□ and the methods of preventing transmission,
□ their ethical and legal duties to provide care, and
□ the existence of significant legal penalties.
5, 2, Futility of Discrimination Against People Living with HIV/AIDS
Of the Universal Declaration of Human Rights is the postulate that all
The
corebeings have equal rights. Denying human rights to people affected y
human
HIV/AIDS is denial of this fundamental right and thus discrimination.
How a government - local, regional, or national - chooses to co^°nt th® ^DSf
epidemic reflects its underlying interests, values, and sterns
we"^s tho’ e f
the society it claims to serve. How a country treats its own people with AIDS and
or those at risk for HIV - thus would reflect its general approach to huma
g
•
HIV/AIDS thus becomes an acid test for a country and its government regarding
respect for human rights.
One of the tragedies of HIV/AIDS phenomenon is that persons living with it have to
Face death and discrimination at the same time. This discrimination is manifested >n
all areas of l?fe hearth care, housing, education, work, travel, etc. Often ignorance
and oreiudice are the sources of this discrimination. It is expressed in particularly
haJsh forms against the most vulnerable sections of the society: the Poor''"om® '
children prisoners, and prostitutes among them , who are often identified with HIV
eoidemicsP Whereas most illnesses produce sympathy and support from family,
£ds and neighbours, persons with AIDS are frequently feared and shunned by
others. Prejudice, stigmatisation and even violence against those* livingw th
HIV/AIDS seem to be a world-wide phenomenon. As Amanda Heggs, AIDS suff
sart^’Sometimes I have a terrible feeling that I am dying not from the virus but
, .
t-Aiirhahip
Thp late Derek Jarman, British filmmaker, artist and
XS! "rrn'nol afraid IXX buoL afraid of dying. Pain can ba aUeviated
by morphine but the pain of social ostracism cannot be taken away.
The net res
o?t™s dtecrlminative feeling is that it hinders our efforts to minimise pain of the
patients and the transmission of HIV.
m the context of AIDS, respect for human rights and dignity of those affected by this
XXTno't only an' eXca, and
discrimination,"those affected will actively avoid detection and contact with health
1 Quoted in: Guardian (London, 12 June 1989).
2 At Your Own Risk: A Saint's Testament, (1992).
6
and social services. The result will be that those most needing information, education
and counselling will be "driven underground." There can no longer be any doubt that
respect for human rights saves lives. Indeed, there has been a realisation that
protection of human rights is a necessary component of HIV/AIDS prevention and
care, and that health and human rights are inextricably linked. Discrimination hurts
the fight against AIDS. Therefore the protection of the rights and dignity of HIVinfected persons is an integral part of the Global AIDS Strategy. In short, human
rights of HIV/AIDS patients must be protected for the following reasons:
(1) because it is their fundamental right;
(2) because preventing discrimination
prevention programme;
helps ensure
a
more
effective
HIV
(3) because social marginalisation intensifies the risk of HIV infection; and
(4) because a society can only respond effectively to HIV/AIDS by expressing the
basic right of people to participate in decisions which affect them.
The protection of the uninfected majority depends upon and is .inextricably bound
with the protection of the rights and dignity of the infected persons. As mentioned
earlier: "If our society cannot take care of a few who are HIV/AIDS affected, it may
not be able to save the many who are healthy."
Three different possible types of discrimination can be listed below in order to point
out how it is counterproductive:
1. Against high-risk groups:
It is meaningless, because, persons who do not belong to this category
place themselves at risk through the sexual behaviour that they choose.
On the other hand, others in the so-called 'risk groups' may well have
chosen to behave in ways which do not place them at risk, whether
abstinence or faithfulness.
2. Against HIV positive people:
The ethical basis for non-discrimination is the ancient principle that
equals should be treated equally - that distinctions should be made
The
between people only on grounds which are morally relevant.
significant thing about someone who is HIV-positive is that, as a carrier
of the AIDS virus, in specific situations, that person may be instrumental
in bringing about the illness and death of another person. So if, for
instance, within the closed and imposed context of a prison, people are
located in different places solely on grounds hat they are HIV positive or
negative, it may be morally justified. It is, however, not a relevant
ground for offering less exercise or worse facilities to them. In addition,
since it would rightly be considered a breach of fundamental rights to
make a person's medical condition a matter of public knowledge, it might
be practically impossible to achieve such segregation without breaching
this ethical principle, unless someone is proved to be intentionally trying
to infect others.
Within society at large, however, where people may choose their
associates, such separation is in most cases unnecessary, HIV is not
transmitted through social contacts. This means that discrimination in
housing or employment against those who are HIV positive is
unjustifiable.
3. Against people with AIDS
7
They must be protected from arbitrary shunning in work or housing as
HIV/AIDS does not spread through social contacts. Therefore social
discrimination towards them people is unjustifiable.
Some suggestions for combating HIV/AIDS-related discrimination:
□ making changes in the area of human
rights
legislation
and
enforcement,
□ creating a more supportive environment for persons living with
HIV/AIDS as well as the groups most affected by the disease,
□ strengthening anti-discrimination laws,
□ expanding legal services.
□ developing more rational insurance practices,
□ educating health-care providers.
The importance of proactive responses that seek to identify the causes of
discrimination and to deal with these before conflict arises, rather than reactive
responses that depend upon those who are discriminated against seeking redress
after the event, is to be stressed, including legislative responses, advocacy, public
declarations by influential individuals or groups, proactive ethical approaches,
educational responses.
The Question of HIV/AIDS and Insurance: Since a level of discrimination is the
essence of insurance policy, especially of health insurance, it may be difficult to
exclude testing and consequent exclusion of HIV-positive people from life insurance.
Some sort of arrangements for the care of the AIDS patients should be one of the
priorities of the government. Let us again remember what the Father of our Nation
Mahatma Gandhi used to say (as mentioned earlier): "any legislation or government
policy should first and foremost think about how it is going to affect the well being of
the poorest and the most marginalised of citizen."
5. 3. The Right to Autonomy of HIV/AIDS Patients
HIV/AIDS patients, in so far as they are competent human persons, enjoy
this basic right of autonomy:
□ "The right to knowledge" and "the right to ignorance": with regard
□
□
□
to understand what is happening to them: the right to knowledge
about their condition, if they so desire; the right not to know what
is happening to them, if they do not want to know.
The right to know and accept what is being done to them with
regard to the diagnostic and therapeutic procedures.
The right to give informed consent
The right to enjoy confidentiality
It is quite evident that this right is not an absolute right. The limit of a person's
rights and freedom is another person's rights and freedom. In the context of the
special nature of HIV/AIDS, let us see how the right to autonomy applies to the
questions of testing for HIV, right to confidentiality, etc.
5. 4. The Question of Testing
The Ethical Advantages of Testing:
8
a. Testing can tell the person tested whether he or she is carrying the virus
or not. This itself may be useful to the individual in two ways: first it
informs the individual of whether or not to expect the onset of a serious
illness, and second, it tells the person whether or not he or she is likely
to transmit a lethal virus to another person by intimate contact.
Those who oppose testing tend to ignore this second extremely important
function. As regards the first, they speak of a 'right to ignorance7. It is
true that the news that one is suffering from something that may lead to
fatal illness is bound to be unwelcome. Nevertheless the second function
of this knowledge should override the right a person might otherwise be
considered to have to maintain peace of mind through ignorance. This
right becomes relevant in relation to proposals for testing the blood
supply, or for conducting anonymous surveys designed simply to
establish the extent of the spread of the virus in the population.
b. Testing can enable a medical professional to treat a person whose
condition might otherwise be misunderstood. It can enable medical
professionals to take appropriate measures to guard against infection in
operating on or otherwise treating the person. It can also enable the
medical professional to discover whether others are involved who might
be at risk, in particular the spouse of a patient and to'consider whether
they are adequately protected.
c. Thus it is hard to justify a right to remain ignorant, unless indeed the
desire to remain ignorant is combined with a willingness to behave as if
one had been tested and the result was positive.
5. 5. Principle of Autonomy and Testing:
The principle of autonomy of the patient demands, however, that HIV testing
should generally be undertaken only with the informed consent of the person
being tested. This for two reasons: potential harms from testing, and respect
for the autonomy of patients.
This, however, does not apply to the testing of donors of blood, organs,
semen, or similar bodily products. In all cases of donations, ethical approach
is that prospective donors should be informed before the performance of the
test that an HIV-related test will be conducted, and given adequate
information about the nature and purpose of the test.
This does not apply to testing performed as part of an anonymous
screening programme for epidemiological or research purposes, though.
HIV
5.6. General Principles for Testing: voluntary or mandatory:
There are several general principles that should guide consideration of all
testing proposals:
□ First, the purpose of testing must be ethically acceptable. Protecting
public health and preventing transmission of HIV are acceptable
purposes, while denying needed services and expressing disapproval of
certain groups are not.
□ Second, the proposed use of test results must contribute to the
programme's goal.
□
Third, the test programme must be the least restrictive or intrusive
means for attaining the programme's purpose.
□ Fourth, the benefit to public health must warrant the extent of
intrusion into personal liberties. This principle does not suggest that
9
public health should be sacrificed in order to protect civil liberties, but
only that an uncertain or minimal public health benefit should not be
used to justify gross invasion of personal rights.
5. 7. The Question of compulsory Testing:
There have been repeated calls, however, for mandatory or compulsory
as^^regnant wom^SeXr^s, ^Xers^p^rsons TcLsXr convicted
of
sexual
assault,
prostitutes,
health-care
workers
and
patients,
and
immigrants. Is it acceptable ethically?
It is true that compulsory testing can be justified ethically in some situations.
For example, when a health care provider is at risk for HIV infection because
of the occurrence of puncture injury or mucosal contact with potentia y
infected bodily fluids, it is acceptable to test the patient for HIV infection even
if the patient refuses consent. When testing without consent is performed in
accordance with the law, the patient should be given the customary pre-test
counselling, though.
syphilis. The conditions under which a mandatory testing programme is
acceptable were defined by the World Health Organisation in 1968.
an ui
—
fulfilled in the case of HIV/AIDS.
Though not all of these ten conditions are
Nevertheless, world-wide, opinion about HIV-antibody testing has varied widely.
□ There are those who recommend screening for all the population: their
□ in the choice of the groups and in the motives of that choice, which are
□ Last, there are those who recommend voluntary screening: they defend
both human rights and scientific inquiry.
Which of these approach can be considered to be ethical by the Church?
We must remember that in the outbreak of HIV/AIDS, policy makers had to
face a public health crisis of catastrophic proportions: the disease is fatal, no
cure or vaccine exists. The number of infected people has been increasing at
an alarming rate. These chilling facts and the public reaction to them made
legislators want to do something, anything that can make a difference.
initially, in the face of the HIV/AIDS epidemic, proposals for mandatory or
compulsory testing were easy to understand. People naturally searched f°r
concrete solutions, and the notion of mandatory testing - coupled perhaps
with forced segregation of persons living with HIV or AIDS - had obvious
superficial appeal. Calls for mandatory or compulsory testing became
common political response to HIV/AIDS, partly because they create the
appearance of taking a strong stand against the threats of AIDS. Moreover,
there were nagging doubts about the credibility of those who denounce forced
testTng For example, how can it be better not to know who harbours the
virus? Are those who reject forced testing trying to protect the individual
rights of AIDS carriers at the expense of the public health.
Over the years, calls for mandatory HIV testing have never stopped^
Motivated by a mix of emotions and ideologies, they have re-echoed, citing
new research findings and targeting different populations. Let us examine the
question of mandatory testing and its merits and demerits further.
10
5. 8. Screening the Entire Population:
Early in the epidemic, some even recommended that the entire population be
mandatorily tested for antibodies to HIV. A popular misconception was that
widespread or even universal HIV testing could identify all who carry the virus
so that they could be isolated and the uninfected majority could be secure
from any risk of transmission. However, wide consensus emerged that it
would be a mistake to enact laws reguiring the entire population to submit to
testing: Concerns for protecting public health support this conclusion, just as
concerns for protecting fundamental rights do; each goal independently
militates against mandatory testing. In particular, it was pointed out that:
□ even if universal testing could be carried out, it could not contain HIV:
false negatives and persons still in the latency period ("window period")
when testing was performed would not be detected; repeat testing would
be necessary to remedy those errors, and in the meantime those
undetected might continue to spread the disease;
□ there is a danger that the "uninfected" population would feel a sense of
security and not pursue precautions against infection, even though that
population could not be entirely secure from HIV-positive persons;
□ a universal or widespread testing programme does not represent a
practicable approach because of the costs it would entail; and,
□ the HIV-negative persons in the population are not in fact at risk from
HIV-positive persons living in their midst: they can protect themselves
against becoming HIV-positive by taking appropriate precautions.
5. 9. Testing of so-called "High-Risk Groups"
Recognising the problems raised by universal testing of the entire population,
some have recommended that mandatory or compulsory testing be limited to
members of the so-called "high-risk groups," in particular homosexuals,
injection-drug users, and haemophiliacs and prostitutes.
However, such proposals were rejected on the basis that HIV is an
indiscriminate virus that does not infect people along group lines: it is a highrisk activity, not identification with a group that is decisive in the transmission
of the virus. In addition, it was recognised that a mandatory testing
programme aimed at the so-called "high-risk groups" would face obvious
problems in identifying members of the targeted groups: testing would be
associated with stigma, and members of "high-risk groups" would be
encouraged to go underground. Finally, mandatory testing of these groups
would have intensified the sense polarisation of "us" and "them" - therefore
increasing discrimination towards "them" and giving "us" a false and
potentially dangerous sense of security.
5. 10. Testing Specific Populations
There is increasingly broad realisation that proposals for mandatory testing
generally are political rather than health policy proposals. As more persons
come to realise these facts and also become dedicated to taking AIDS
seriously, they reject most of the proposals for testing for HIV by specific
groups.
Because there are problems both with forced testing of the entire population
and with testing of "high-risk groups," some have called for more targeted
mandatory testing programmes. One or more of the following four factors
seem to underlie the proposals for testing of certain groups:
11
□ A perceived high risk of being HIV-positive;
□ A perceived high risk of infecting others with HIV;
□ Attribution of culpability due to involvement in criminal activity, so that
being required to undergo the test can be considered a just component
of punishment;
□ Perception of some use that can be made of test results.
For example, some argued that testing should be required among prisoners,
arrested prostitutes and drug users, and those who attend sexually
transmitted disease- and drug-abuse clinics. In this view, these groups are
not only at a high risk of infection, but they also pose a serious risk to the
health of the community and are likely to transmit the disease to innocent,
healthy members of society.
Each type of testing proposal raises a unique set of policy issues, and
therefore it will be considered separately in section 6. 8. below.
For
example, proposals to test all pregnant women raise different concerns and
implications from proposals to test all prisoners.
Mandatory or compulsory testing, whether of the entire population or of
enarifir
specific nmimQ
groups, ic
is npnpmllv
generally nnoosed
opposed because of the following reasons:
□ Because of the potential for invasion of privacy and discrimination.
□ Because of the stigmatisation and discrimination directed at HIV-
infected people, individuals who believe they might be infected tend to
go "underground" to escape mandatory testing. As a result, those at
highest risk for HIV infection may not hear or heed education
messages about AIDS prevention.
□ Testing without informed consent damages the credibility of the health
services and may discourage those needing services from obtaining
them.
□ In any testing programme, there will be people who falsely test
negative - for example, because of laboratory error or because they
are infected but have not yet developed detectable antibodies to HIV.
Thus, mandatory testing can never identify all HIV-infected people.
□ Mandatory testing can create a false sense of security especially
among people who are outside its scope and who use it as an excuse
for not following more effective measures for protecting themselves
and others from infection. Examples are health care workers who do
not follow universal precautions when all hospital patients are tested,
and clients of sex workers who do not use precautions when they
believe that all prostitutes are being tested.
□ Mandatory testing programmes are expensive, and divert resources
from effective prevention measures.
Other international organisations have made similar statements. For example,
the Council of Europe adopted a recommendation stating that "in the absence
of curative treatment, and in the view of the impossibility of imposing
behaviour modification and the impracticability of restrictive measures,
compulsory screening is unethical, ineffective, unnecessarily intrusive,
12
discriminatory and counter-productive."3 The Joint United Nations Programme
on HIV/AIDS (UNAIDS), in its 1997 Policy on HIV Testing and Counselling,
also expressed its opposition to mandatory testing stating that "HIV testing
without informed consent and confidentiality is a violation of human rights."
Finally, the International Guidelines on HIV/AIDS and Human Rights
recommend that HIV testing only be performed with the specific informed
consent of the individual tested, and that "exceptions to voluntary testing
would need specific judicial authorisation, granted only after due evaluation of
the important considerations involved in terms of privacy and liberty."4
This conclusion is consistent with WHO's Statement from the 1992
Consultation on Testing and Counselling for HIV Infection, which emphasises
that "mandatory testing and other testing without informed consent has no
place in an AIDS prevention and control programmes."5 The Statement
continues by saying:
There are no benefits either to the individual or for public health
arising from testing without informed consent that cannot be achieved
by less intrusive means, such as voluntary testing and counselling.
Public health experience demonstrates that programmes that do not respect
the rights and dignity of individuals are not effective. It is essential, therefore,
to promote the voluntary co-operation of individuals rather than impose
coercive measures upon them.
The following are the specific groups which are often referred to as useful
candidates for testing:
i) Pregnant Women:
The legal and ethical background for HIV testing requires respect for the
conditions of informed consent, pre- and post-test counselling, and
confidentiality. As with any other patient, pregnant women and women who
are intending to conceive need to fully understand the advantages and
disadvantages of HIV testing before deciding to undergo the test. The
discovery of a HIV -positive status has important implications for decisions to
interrupt pregnancy, to take antiretroviral therapy should pregnancy continue,
and to breastfeed - decisions which themselves are mostly voluntary in
nature. Help must be given to meet the challenge of ensuring that all HIVinfected women who desire to continue a pregnancy are offered effective
means to reduce the risk of HIV transmission to their babies while respecting
the rights of all pregnant women, the majority of whom will not have HIV
infection, to decide for themselves whether or not to be tested for HIV. Ever
since the discovery was made that administration anti-retroviral therapy, such
as Zidovudine (AZT), significantly reduces the danger of HIV transmission
from the mother to the child, the clamour for compulsory testing of pregnant
women has increased. Ethically, however, the importance must be stressed
of allowing women to make decisions about testing as well as AZT use in a
non-coercive atmosphere and based on the balance of the benefits and
potential risks of the regimen to herself and her child.
ii) New-borns:
3 Recommendation No. R (89) 14 of the Committee of Ministers to Member States on the Ethical Issues of
HIV Infection in the Health Care and Social Settings.
4 HIV/AIDS and Human Rights - International Guidelines, recommendation 28(b).
5 WHO, resolution WHA 45.35, 14 May 1992.
13
Unlike programmes directed at offering voluntary HIV testing and counselling
to all pregnant women - coupled with voluntary treatment, if necessary testing of new-borns does not have the benefit of substantially reducing the
risk of transmission from mother to baby, except to the extent that a positive
test might indicate a need to discontinue breastfeeding in order to prevent
any further risk of transmission, assuming transmission has not already
occurred. Therefore, it can been said that mandatory new-born testing is the
wrong answer to the wrong question.
The right question is: How can we offer appropriate counselling to all women
and engage them voluntarily to learn their HIV status? If they are HIV
positive, how do we ensure that they receive needed care for themselves and
potential interventions to prevent transmission to their foetus and, finally,
that they provide care for their infants? With appropriate resources given to
education and health care, the desired goal of early identification and
treatment of HIV-infected infants can be accomplished without mandatory
new-born screening.
Women who tested positive during pregnancy (or before), as well as women
who refused HIV testing during pregnancy, but are considered to be at risk by
their health-care provider, should be asked to consent to testing of their new
borns. Refusals should generally be respected. Testing of an infant without
the parent's consent may, however, exceptionally be justified in a few
circumstances, when a court decides that it is necessary, effective and the
least invasive and restrictive means available to achieve the aim of benefiting
the infant. This could be the case, for example, when a physician has reason
to suspect that a child suffers from an HIV-related illness, the parents' and
the child's HIV status are unknown, the parents refuse to give consent to
testing, and knowing the child's HIV status would be necessary to decide how
the child's illness could best be treated.
iii) Prisoners:
It does not seem that their exists any public health or security justification for
compulsory or mandatory HIV testing of prisoners, or for denying inmates
with HIV/AIDS access to all activities available to the rest of the population.
Rather, prisoners should be encouraged to voluntarily test for HIV, with their
informed, specific consent, with pre- and post-test counselling, and with
assurance of the confidentiality of test results. As do people outside prison,
they should have access to a variety of voluntary, high-quality, bias-free
testing options, including anonymous testing. Ensuring that HIV-related
medical information remains confidential is particularly important in prisons
because potential harms from testing for prisoners may be especially great
because of the higher potential for stigmatisation and discrimination.
iv) Sexual Offenders:
Testing sexual offenders like rapists, by itself, may not best serve to assist
victims of these offenders. It may provide some relief to victims, but
programmes that include counselling, monitoring of victims' own health
status, and emphasis on their own well-being may generate greater long
term benefits.
The issue of compulsory testing of persons accused and/or convicted of
sexual assault has often been characterised as being one of choosing between
the accused's rights and victims' rights. However, to attempt to characterise
the choice whether or not to require HIV antibody testing of accused persons
as being either pro-woman or pro-criminal tends to obscure the real
complexity of the issue and the tangible needs of the survivor. In so doing
there is a danger of manipulating the survivor's understandable feelings of
14
anger, frustration and fear in order to advance a position that ultimately will
not help her.
There can be no question that persons convicted of sexual assault have
committed a serious criminal offence - if compulsory testing could further
some useful objective for the survivor of the assault, it might be appropriate
to regard the convicted person's claim to autonomy as appropriately of less
weight.
However, as demonstrated above, compulsory testing and disclosure of the
test result to the survivor of a sexual assault provide little if any benefit to the
survivor. Testing a person convicted of sexual assault cannot provide the
survivor with useful information. At the time of conviction, she can find out
whether she herself is HIV-positive by undergoing testing. In contrast, testing
the offender would only provide her with information about the offender's
HIV-status.
In contrast to persons convicted of sexual assault, persons accused of sexual
assault are innocent until proven guilty. Therefore, it is not at all clear how
compulsory testing could even be legally performed on them. Not having been
convicted, testing could not be imposed as part of the .punishment of the
accused person. Merely having been accused of sexual assault is unlikely
sufficient grounds to establish such a threat.
v) Commercial Sex Workers:
Laws under which prostitutes may be required to refrain from specific
conduct, undergo specified treatment or counselling, submit to supervision,
undergo treatment while detained, or, if infected with HIV, be detained, may
be counterproductive. These compulsory measures will dissuade prostitutes
to come forward for public testing for HIV infection. Moreover, clients are
absolved of any responsibility for using precautions because the effect of the
legislation leads them to assume that working prostitutes will be 'clean'.
Rather than such measures, interventions are necessary that would give sex
workers the means to protect themselves against HIV transmission and would
empower them to use them. This will also necessitate an analysis of the
impact of laws regulating and/or penalising prostitution on efforts to prevent
HIV infection.
The use of condoms must be evaluated in this context. The truth is that
condoms are not considered to be sure means of prevention of the spread of
HIV/AIDS. In the context of commercial sex workers continuing in their life
style, however, it can be considered as part of harm reduction efforts.
vi) Health Care Workers:
Should health-care providers be required to undergo compulsory testing for
antibodies to HIV; if positive, should they be excluded from practising, or
required to disclose their HIV status to their patients?
The general opinion is against a position that would require testing for
antibodies to HIV and restrictions on a wide range of health-care
professionals, but equally against a position that would set no limits on
health-care workers living with HIV/AIDS. The most appropriate way to frame
the question is to ask how best can patients be protected against real risks,
while not overreacting and excluding competent and safe practitioners. In
order to best protect physicians as well as patients, the emphasis needs to be
on strict adherence to infection-control practices rather than on efforts to
detect who is infected. The emphasis given by political figures to protecting
the patient from the HIV-infected health-care provider seems to misdirect
15
efforts and resources away from activities that would do the most to protect
the health of the public - namely the procedures that emphasise good
infection-control practice. HIV-positive health-care providers have saved and
continue to save thousands of lives every year, and that excluding them from
exercising their profession would endanger their patients' lives, and ruin the
lives of thousands of dedicated medical professionals.
vii) Visiting foreigners:
It does not seem to be befitting human dignity and international etiquette to
screen all the foreign visitors to our country for HIV status. For one thing,
their 'foreigness' does not pose any health hazard to any one as far as HIV is
concerned.
Regarding visitors who are proven to be HIV positive the
individual circumstances of each case should be taken into account, weighing
the costs against the benefits of allowing a particular person to immigrate or
to visit, and take humanitarian concerns into account.
Regarding foreign students who are going to be on scholarships, it is a
different matter. Conditions can and should exist for qualifying for such
privileges and people remain free to apply for them or not.
5, 11. Confidentiality:
The right to confidentiality is one of the important rights of the patient. The
information disclosed to a physician during the course of the relationship between
physician and patient is confidential to the greatest possible degree. The patient
should feel free to make a full disclosure of information to the physician in order that
the physician may most effectively provide needed services. The patient should be
able to make this disclosure with the knowledge that the physician will respect the
confidential nature of the communication. The physician should not reveal
confidential communications or information without the express consent of the
patient, unless required to do so by law.
The obligation to safeguard patient confidences is subject to certain exceptions which
are ethically and legally justified because of overriding social considerations. Where a
patient threatens to inflict serious bodily harm to another person or to him or herself
and there is a reasonable probability that the patient may carry out the threat, the
physician should take reasonable precautions for the protection of the intended
victim, including notification of law enforcement authorities. Also, communicable
diseases, suspected medico-legal cases, should be reported as required by law. If a
physician knows that a HIV-positive individual is endangering a third party, the
physician should, within the constraints of the law, (1) attempt to persuade the
infected patient to cease endangering the third party; (2) if persuasion fails, notify
authorities; and (3) if the authorities take no action, notify the endangered third
party.
These principles regarding confidentiality in general applies to HIV-related
information as well.
The confidentiality of the results of HIV testing must be maintained as much as
possible and the limits of a patient's confidentiality should be known to the patient
before consent is given.
5, 12. Obligation to Report HIV status
Generally speaking, when reporting of both HIV and AIDS is necessitated by
law, it should be done anonymously: nominal reporting is not warranted
either for surveillance or for partner notification purposes.
Test providers, ethicists, public health professionals, technical experts and
others have to develop a system that collects only the information necessary,
16
using unique or coded identifiers that ensure privacy and confidentiality of the
individual. If it is not done in a way that the confidentiality is protected, the
studies are going to totally biased because of the non-co-operation of the
general public.
Also the communication media have to exercise a lot of self-discipline in this
matter. The inhuman persecution that followed careless reporting by the
communication media of some HIV/AIDS patients in our Country is well
known. 'Do to others, as you would have them to do to you' has been the
golden rule of ethics down the ages.
5. 12. 1. Partner Notification
When a married person is tested positive for HIV, should the medical
professionals or authorities inform the partner about it? If the person is likely
to infect the partner, certainly there is an obligation on the part of the
medical professionals to divulge the information to the partner. Convincing
the person to share this information with the partner would be much more
effective and conducive to prevent the spread of the contagion.
It would be a better policy to inform each person who requests HIV testing
and counselling, under which circumstances the partner will have to be
notified in case the test proves to be positive.
While most agree that there are situations in which breaching confidentiality
would be justified ethically, such breaches raise difficult questions: What will
occur if it becomes generally known that clinicians breach confidentiality to
protect third parties? Will patients cease to speak with candour about their
behaviour? Will the public health suffer as a consequence?
Here we are facing an extraordinary irony: the ethics of the clinical
relationship, which usually favours strict confidentiality, appear to dictate a
breach of confidentiality in the matter of partner notification, while the ethics
of public health, which are usually less concerned with confidentiality, may
dictate a stricter adherence to it.
It would be more beneficial to analyse the reasons why a client refuses to tell
his or her sexual partner about his or her HIV-positivity. Working through of
deep-rooted issues of rejection, abandonment, loneliness, and infidelity may
be more effective for prevention of the spread of AIDS rather than police-like
reporting practices.
5. 12. 2. Confidentiality of HIV Status on Autopsy (post mortem) Reports
In the same vein, it is clear that health care professionals have a serious duty
to maintain the confidentiality of HIV status on post-mortem reports.
Physicians who perform autopsies or who have access to autopsy information
regarding a patient's HIV status should be familiar with state law governing
(a) the reporting of HIV and AIDS to public health authorities; (b) obligations
to inform third parties who may be at risk for HIV infection through contact
with an HIV-infected dead person; (c) other parties to whom reporting may
be required like funeral directors, embalmers, etc. This includes reporting to
organ or tissue procurement agencies if any parts of the decedent's body
were taken for use in transplantation.
5. 13. Ethics of Legislation about HIV/AIDS
One of the responses to HIV/AIDS has been an "epidemic" of laws and policies
enacted by many countries all over the world. These laws relate to public health, civil
liability for HIV transmission, discrimination, homosexuals, sex workers and their
clients, employment, injecting-drug-use, therapeutic and preventive goods (including
17
condoms, HIV test kits and injection equipment), the media, broadcasting,
censorship, and privacy, etc. As early as May 1991, the World Health Organisation
listed 583 laws and regulations concerning HIV infection and AIDS from different
countries. To this, more than 170 laws from the United States had to be added.
The effectiveness of this legal response, however, has to be evaluated. In the words
of one legal expert, this "juridical outburst," while it may have solved some
problems, has caused the appearance of "a new virus, 'HUL' (=for Highly Useless
Laws)."6 It is generally agreed that many of the legal or policy responses to
HIV/AIDS are useless and often can be harmful and counterproductive because,
instead of being based on an understanding of the medical issues, medical research
and its findings, they are driven more by fear and the resulting public demand for
action. Some law makers, who show a willingness to practice demagoguery by
placating or stimulating false and irrational fears through proposed enactments or
decisions, often ignore established medical evidence.7
We know that the legal response to HIV/AIDS is important, but what should the legal
response actually be? Legislation in this matter should be able to assist in strategies
for the care and treatment of people with HIV and help to reduce the spread of HIV.
The approach of the law in responding to AIDS should encourage the cooperation,
confidence and trust of those infected and at risk by protecting their dignity and
integrity.
There could be three main models through which the law can be incorporated into
HIV/AIDS policy:
(1) The traditional proscriptive model that penalizes certain forms of conduct;
(2) The model that focuses on the protective function of the law and the need
to uphold the rights and interests of persons living with HIV/AIDS; and
(3) A third model that seeks to use the law actively to promote the changes in
values and patterns of social interaction that lead to susceptibility to HIV
infection.
(1) A large number of countries have adopted provisions for compulsory reporting of
HIV and AIDS, provided penal sanctions for knowingly spreading HIV, established
procedures for mandatory testing for HIV, or enacted other proscriptive laws directed
specifically at HIV/AIDS. The coercive nature of such laws, far from encouraging
conduct that will reduce the spread of HIV, may actively impede prevention efforts
by alienating those people who are at risk of HIV and making it less likely that they
will cooperate in prevention measures. Lawmakers must be sensitive to not only the
direct but also the indirect impact of legal sanctions. The particular dynamics of AIDS
and HIV infection suggest that proscriptive laws will rarely be an appropriate policy
response if they seek merely to target the conduct of people with HIV or activities
that give rise to HIV infection risks. In this guise, the role of the law is a negative
rather than a positive one, and the challenges of HIV/AIDS are such that an effective
policy requires more than negative prohibition. Of all the different models the law
can follow, the proscriptive model has the least scope for a creative application to
policy formulation.
(2) The second model for the role of law in HIV/AIDS policy focuses upon how the
law can protect people from discrimination, breaches of confidentiality, and other
harmful and undesirable occurrences. This model has been of central importance in
6 Justice Kirby, at the Symposium international de reflexion sur le SIDA, Paris 22-23 October
1987; see also Kirby M. The New AIDS Virus - Ineffective and Unjust Laws. Journal of Acquired
Immune Deficiency Syndromes 1988; 1: 304-312).
7 see Hermann DHJ. AIDS and the Law. In: Reamer FG (ed). AIDS & Ethics. New York: Columbia
University Press, 1991,277-309
18
the context of the legal response to HIV/AIDS because of the proliferation of
discrimination against people with HIV and because of the increasing recognition,
both nationally and internationally, of the interplay between AIDS and human rights.
Protective laws may help to enlist the support and cooperation of people at risk of
HIV in prevention strategies. Decisive and firm legal intervention may be what is
required in the context of measures to protect the rights of people with HIV.
(3) The third model for legal intervention mentioned above is the most controversial,
but arguably may also be the most important. It operates on a broader and more
far-reaching level and suggests that the law can play a proactive role not merely in
mediating rights and obligations as between individuals but also in seeking to change
underlying values and patterns of social interaction that create vulnerability to the
threat of HIV infection. The challenge for HIV/AIDS policy is to recognise the need to
address not only what might be called the 'HIV/AIDS-specific' issues, such as HIV
education programmes and research into new barrier methods to prevent HIV
transmission, but also the underlying social and economic factors that deprive
individuals of the power to protect themselves against HIV infection. The law can be
used as an instrument to provoke or reinforce the required changes, "as a sword
rather than a mere shield." These interventions will require a creative approach to
the law, which recognises that the law can play more than just a direct proscriptive
or protective role. With such an approach, there is a real potential to use the law
proactively and constructively in the response to HIV/AIDS.5.
5. 14. Criminalization of HIV Transmission
Whether or not the criminal law should be used to deal with the behaviour of persons
living with HIV/AIDS who put others at risk of contracting HIV is one of the most
hotly debated topics.
Any person who engages in any high risk behaviour knowing that he or she has been
infected with the human immunodeficiency virus is certainly committing a criminal
offence.
In attempting to "criminalize" certain behaviour by people infected with HIV, the
criminal justice system at times tends to ignore the conclusions of public health
officials. The strategy of some prosecutors of charging people with serious crimes for
committing certain acts while knowing they are infected, discourages people from
learning their HIV status and seeking diagnosis and treatment. Further, by
attempting to charge people with serious crimes for actions that cannot transmit the
virus, criminal justice system is undermining efforts to educate people about the real
risk of transmission. There is a real risk that judges and juries will punish people not
because they have committed dangerous acts, but because they are homosexuals or
prostitutes or use drugs. These prosecutions also permit judges to punish people for
being infected with HIV.
Amending the Criminal Code to create an HIV-specific offence should be done very
cautiously. In particular this can send out a message that all persons living with
HIV/AIDS are potential criminals, that the uninfected are potential innocent victims;
and that one need not protect him/herself because the law is there to protect. The
question is whether public health laws would not be better suited than criminal law
to deal with those individuals who, knowing that they are infected, engage in
behaviours likely to transmit HIV without using precautions and without previously
informing their partners about their HIV status.
Many argue that traditional criminal laws are ill-suited to the context. They seem to
be ineffective and inappropriate in dealing with conduct likely to transmit HIV. Unlike
traditional penal laws, statutes made in many countries regarding HIV do not require
proof of either "harm," "causation," or "state of mind": it is sufficient that the
accused engaged in the forbidden behaviour - persons would commit a criminal
offence if, knowing that they are HIV-infected, they engage in sexual intercourse or
19
other activities that could potentially transmit HIV, without previously informing their
partner about their positive HIV status.
Some argue that that the threat posed by HIV is such as to require all reasonable
measures of containment to be seriously examined, including the use of the criminal
law. Anyone who knowingly engages in high-risk conduct and does not inform the
other participant deserves condemnation, and the strongest way to express that
condemnation is through the criminal law.
However, it must be pointed out that in this matter use of criminal law serves only a
limited purpose. For example, in a case where individuals knowing they are infected
choose to engage in behaviour that will likely lead to the infection of others, criminal
prosecution for the purpose of punishment and deterrence can be justified .
However, the use of the criminal sanction to punish and deter conduct likely to result
in transmission of HIV may not lead to achieving the purposes of the criminal law
and its efficacy in dealing with problems such as HIV transmission.
Also, creating
a provision that would deal only with HIV/AIDS, thereby singling out HIV/AIDS from
other serious communicable diseases is blatantly unfair to HIV/AIDS patients. The
principle concern here must be prevention through education and adequate
information rather than the possibility of imposing penalties whenever they might
appear necessary. The criminal justice system may not be an inappropriate
mechanism through which to combat the AIDS crisis. Cnminalisat.on of HIV
transmission would encourage people to avoid testing, threaten the PriYa(=y of sexual
relationships and encounters, and raise a risk of official harassment and abuse.
Even those who argue in favour of using the criminal law often concede that it has
only a minor role to play •ini preventing the spread of HIV and that ultimately the
major role will be played by education rather than coercion
5, 15.Ethics of Developing Drugs Against HIV/AIDS
In 1980s when AIDS broke out, the system regulating the approval of new drugs
underwent some changes, partly as a result of AIDS activism. There certainly was
a conflict between the anxiety and urgency perceived by those seeking access to
new drugs and treatments on the one hand, and scientific method, on the other
hand Both had their justifications and both sets of demands must be seen as
legitimate. However, it is ethically very important to conserve the central points of
the philosophy of drug regulation. Generally speaking drugs should not be licensed
for marketing until they have proved safe and effective under proposed conditions
of use. Any change in the process regulating drug approval should be at least
consistent with, if not positively enhancing of, the ability to speedily conclude sound
scientific evaluations of any new treatments. On the other hand, it can be said that
people with life-threatening illnesses like AIDS or cancer have exceptional rights,
and should be allowed access to experimental drugs before these have been
formally approved.
Often the medical profession and patients become pawns in the hands of
manipulative drug industry. As Barbara Ehrenreich, the US author wrote: "From
price of $8,000 an annual dose, and w^hich has the added virtue of not diminis i g
the market by actually curing anyone."8
8 The Worst Year s of Our Lives, “Phallic Science” (1991; first published 1988).
20
4
The important tenets of a healthy drug-policy should prevail in order to remedy
potential manipulations and exploitation by the drug industry of both the medical
profession and the patients
5. 16. Drug Addicts and HIV/AIDS
Until the outbreak of HIV/AIDS, drug-addiction was considered in general as law and
order problem, or a crime. The advent of the AIDS pandemic has fortunately turned
out attention to the real nature of drug-addiction as a public health concern. A
sensible strategy in dealing with drug-addiction would be to aim at harm
minimisation, rather than total legal prohibition.
Instead of reaching out to the drug addicts with the healing touch that they require,
often they were discriminated against and ostracised. A group that was often most
in need of services was denied access or actively discouraged from accessing these
services. Even more disturbing is that this treatment of drug-addicts seems so
acceptable to society.
The existing drug laws in many countries negatively affect efforts to prevent HIV
infection and to care for HIV-positive drug users. The drug users,' rather than being
offered easy access to treatment for both their drug use and HIV/AIDS, are being
"driven underground." Existing laws and policies in many countries make it difficult
to reach and educate them. It is because drug use is treated as a criminal activity
rather than a health issue. They create a culture of marginalised people, driving
them away from traditional social support networks. They foster a reluctance to
educate about safe drug-use practices, for fear of condoning or encouraging the use
of illegal drugs. They foster public attitudes that are vehemently anti-drug user,
creating a climate in which it is difficult to persuade people to care about what
happens to their fellow citizens who use drugs. They focus too much attention on
punishing people who use drugs, thereby downplaying critically important issues
such as why people use drugs and what can be done to help stop unsafe drug-use
practices.
There can be no question that concern about HIV/AIDS, especially about the
connection between the sharing of contaminated needles and the spread of HIV, is
having an important impact on the course of drug-prevention policy. Many are
officially embracing the so-called "harm-reduction approach" to drug use. Under this
approach, the first priority is to decrease the negative consequences of drug use
rather than its prevalence. Harm reduction "establishes a hierarchy of goals, with the
more immediate and realistic ones to be achieved as first steps toward risk-free use
or, if appropriate, abstinence". Some people fail to make a distinction between harm
reduction approaches and approaches advocating decriminalisation of drugs. But the
difference is clear: a harm-reduction approach may or may not include the goal of
decriminalisation of drug use, but, even if it does, this will only be one of many
components of a strategy to reduce the harms from drug use, rather than its primary
goal. Supply of clean needles should be seen in this context, and not in the context
of promoting a permissive attitude towards drug use.
5. 17. Homosexuals and HIV/AIDS
Human Immunodeficiency Virus can spread through any intimate sexual contact,
whether it is heterosexual or homosexual. The routes of contagion are usually used
as a norm to demarcate HIV/AIDS population into two categories: the guilty majority
and the innocent minority. Gay men, injection drug users and promiscuous men and
women are supposed to belong to the first category, and haemophiliacs or
transfusion cases to the second category.
The fact is that human immunodeficiency virus is the same whichever way it enters a
human body. Its effects are also more or less the same for everyone. We may have
21
I
different moral or ethical convictions regarding different sexual orientations or
addictions. Once a person is affected by HIV, it is unethical, though, to discriminate
against him/her on the basis of our moral convictions about various sexual
orientations and moral aversion towards addictions. The ethical duty of everyone is
to reach out to those unfortunate fellow human beings with compassion and care.
Statements like "AH gay men have AIDS and are infectious," or "Gay men are to
blame for AIDS," or "A// drug addicts have AIDS and are infectious," are as absurd
like statements like "AH heterosexuals have AIDS" because AIDS can spread through
heterosexual contacts too.
Often people with HIV infection or AIDS are not referred to as members of a single
community or society to which we all belong, but as "them." This process of creating
"Us" and "them" is called a process of "disidentification." This process of
"disidentification" is inherent in all forms of discrimination. The truth is that one
cannot discriminate against others and treat them in a way that one would find
seriously harmful to oneself unless one can "disidentify" from them and consider
them as somehow "different" from "us." HIV/AIDS is a good example of this. Most
citizens are not involved in the AIDS fight: they are uninvolved because they do not
perceive themselves to be at risk of infection; others are - they are different. Gay
and bisexual men and intravenous drug users represent the "them” to a large
majority of the population. Persons infected, or perceived to be infected, with HIV
are regarded as alien and threatening. This is one of the most unethical attitudes
that is condemned in the Sacred Writings of all the religions in our country, and this
attitude can be described as one of "self-righteousness."
5. 18. Prostitution and HIV/AIDS
Usually public health initiatives and media accounts emphasise the role of prostitutes
as people who infect others rather than people who are infected by others. People do
not seem to be concerned about whether prostitutes themselves get infected from
their clients and die. The only discussion is whether they transmit the virus to their
male customers, who then pass it on to their ’innocent' wives and children. All over
the world, prostitutes are being made the scapegoats for heterosexual infection. This
scapegoating is taking place in the context of a general viewing of women as vectors
for transmission of the disease to their male sex partners ... and their babies. Laws
were introduced to protect the interests of prostitutes' clients, considered to be
potentially innocent victims of AIDS, at the expense of prostitutes, on whose side
guilt is deemed to lie.
Certainly, there is a legitimate community interest in regulating, and in some places
controlling and prohibiting, prostitution.
Earlier we have dealt with the question of mandatory testing directed prostitutes,
and suggested alternative ways of reducing the spread of HIV among prostitutes and
to their clients. The main reason against targeting prostitutes for forced testing is
that it simply won't work as a prevention strategy, because it will drive them
underground. The attitude of compulsory measures, which focus exclusively on
prostitutes, but not on clients, is evidently unjust and unethical.
Rather than coercive measures, as it was pointed out earlier in this Unit,
interventions are proposed that would give prostitutes the means to protect
themselves against HIV transmission and would empower them to use them, like the
development of educational strategies for reaching prostitutes, giving them accurate
information about the ways of preventing transmission, and supporting them in their
efforts to utilise these measures consistently, provision of income and job training
alternatives for those who wish stop working in the sex business, welfare payments,
so that women aren’t forced into prostitution by economic need, and for women who
want to get off prostitution.
22
*
The importance of examining existing laws on prostitution was also recognised by
the World Health Organisation, which held a consultation on HIV epidemiology and
prostitution in 1989. One of the recommendations put forward by the consultation
was to organise a meeting "with appropriate representation from the international
legal and civil rights communities" to address issues such as "laws which impinge on
social, economic, and legal rights of prostitutes and therefore impede HIV prevention
efforts."9
5. 19. Women and HIV/AIDS
The HIV/AIDS pandemic highlights plight of human beings who are victims of the
world's most pervasive inequality - women. The HIV epidemic seems to have taken
the age old the sexual, economic and cultural subordination of women and translated
it into a death sentence for women. The virus exposes the vulnerability of women,
leaving them powerless to protect themselves against infection. The response to the
epidemic should not fail to recognise that the disadvantaged status of women is the
cause of their vulnerability to HIV and should not refuse to permit the rights and
needs of women to play a part in shaping HIV strategies.
The most striking feature in dealing with women and HIV/AIDS i$ that it deals with
women as mothers or as future mothers, and comparatively rarely about women as
women and the many problems they face in dealing with HIV/AIDS.
As pointed out earlier, ever since the finding that administration of AZT to pregnant
HIV-positive women can reduce transmission of HIV from mother to child, many
people are advocating compulsory testing of pregnant women, women of
childbearing age, and/or new-borns. The concern was and is the reduction of HIV
transmission from mother to child, and the early detection of HIV infection in new
borns. Before the discovery of the effectiveness of AZT, the fear was that a
compulsory screening programme among pregnant women would lead to advocacy
for abortion, and would take women's reproductive choices away from them. We
have dealt with the issue of testing pregnant women for HIV earlier in section.
The ethical issue here is that women who are not pregnant or of childbearing age
find it difficult to access HIV testing. This raises the issue of whether there is less
concern about the welfare of women than for that of their children or potential
children. Provisions must be made that testing of women should always be
accompanied by concurrent legal protection for them, such as anti-discrimination and
informed consent laws, and it must be linked to the availability of early clinical
intervention programmes to them.
Attempt to address the needs of women and children with HIV must, for reasons
both ethical and pragmatic, be broadened to encompass more of the women's own
health and support needs. Women must not only receive the message that health
systems are interested in them only or primarily because of their children.
Woman's varying life situations should be systematically taken into consideration in
the formulation of responses to the epidemic.
5. 20. Poverty and HIV/AIDS
Even poverty becomes a reality in relation to HIV infection - some people become
poor because they have AIDS and people who are poor can be more at risk. When
informed about the fatal nature of HIV infection, the statement that a poor man
living below poverty line in India made was: "I prefer to die of AIDS than of poverty
and famine." Especially in developing countries poverty seems to play a central
causal role in AIDS epidemic. Therefore many see the relief of poverty as a key to
prevention of HIV/AIDS, especially in these countries. It is true that programmes to
9 Global Programme on AIDS and Programme of STD, 1989.
23
«
combat AIDS in the developing countries are inevitably drawn into the wider
economic and social problems of the people with whom they are involved
It is true that AIDS has become a major political issue. It is good to an extent
because action in national and international level can be promoted to combat the
disease in the context of eradicating poverty. The unacceptable side effect of
politicisation of HIV/AIDS, however, is that it tends to divide human beings some as
privileged and others as underprivileged. The disease is often seen by many
people, as an affliction of marginal groups. As a result, they tend to see the ethical
and legal issues generated as essentially matters of fundamental rights:
the
marginal groups have to be protected against the discrimination that is prompted by
their assumed connection with a lethal and incurable infectious disease. Here the
responsibility to guard against the spread of infection here is considered to be the
responsibility of everybody else, not of the victims. Others, perceiving the issue in
terms of guilt and innocence, of morality and immorality, seeks solutions in
legislation directed against the target groups. What is needed here is the necessity
is to be united and have the fellow-feeling and a common sense of human
vulnerability in dealing with HIV/AIDS.
24
s
• Pandemic: Global,
encompassing.
The Global Epidemiology of
HIV/AIDS:
Current and Future Trends
II
Presentation by Rev. Robert J. Vitillo
At Special Consultation of Bishops and Leaders
of Major Health Organisations
Bangalore, India
August 8-9, 2003
•Global AIDS is a
pandemic
Epidemic
vs.
Pandemic
G
•Epidemic: Occurs in one
locale for a limited time.
•Specific countries and local
areas have distinct epidemics
of HIV.
HIV/AIDS, malaria and TB:
disease burden and mortality, 2000
Historical Lessons
• AIDS is comparable in magnitude to the worst and
most tragic pandemics in human history, which
have tended to infect 20%-50% of certain
populations.
• Scarlet fever, plague, smallpox and typhus were
respectively held responsible for the military loss
of the Athenians, the destruction of the Roman
Empire, the defeat of the Aztecs and Incas in the
Americas, and the defeat of Napoleon at Waterloo.
Deaths
Lost Healthy Life Years
[HLYs] (millions)
(millions)
• HTV/AIDS
90.4 (54%)
2.9 (52%)
• Malaria
40.2 (24%)
1.1 (19%)
• TB
35.8 (22%)
1.7(29%)
Source: Steven Forsythe, ^Infectious Disease: historical lessonsfor the age of
AIDS,” AIDS Analysis Africa 10(3) Oct/Nov 1999.
Global estimates for adults and children
end 2002
People living with HIV/AIDS
42 million
. New HIV infections in 2002
5 million
Adults and children estimated to be living
with HIV/AIDS as of end 2002
ww
: Deaths due to HIV/AIDS in 2002
firiiSaa.
Sob.atMw
. ..J
...
3.1 million
•
<
...
.iMrtt
iiwXjr*
■
999^4
Total: 42 million
—
..................
1
i
Estimated number of adults and children
newly infected with HIV during 2002
'i
|
>1
‘
Hi
...
...
w.ntretaw'.
it
... 4JtoUbfMt
■
%
J-
...ism
iurts’Xjk*'"’
JirtOeao
42m
I
U«r. Kstru
3?m
Abua :
4WO.HM.
4H '
<1# J
Total: 5 million
Total: 3.1 million
About 14 000 new HIV infections a day in 2002
HIV in Sub-Saharan Africa
More than 95% ar? in developing countries
• By far the worst-affected region, sub-Saharan Africa is now home to
fryv>w.
_
2000 are in children
childrei under 15 years of age
29.4 million people living with HIV/AIDS.
• Approximately 3.5 million new infections occurred in 2002, and 2.4
.
million died during that same time period.
. In 4 southern African countries, national adult HIV prevalence has
risen higher than though possible, exceeding 30%
: About 12 000 are in persons aged 15 to 49 years,
- Botswana (38.8%), Lesotho (31%), Swaziland (33.4%), and
1
Zimbabwe (33.7%)
• Food crises in the latter 3 countries are linked to the toll of HIV.
-about 50% are 15-24 yearolds
§^g.
A
HIV prevalence in adults
in sub-Saharan Africa, 1986-2001
Leading causes of death
in Africa, 2000
26 0
20.0
16.0
Total
I '=
20-39%
K&fl 10-20%
-“fiS
6.0
0.0
Carebro
vucutar
rat^ntary
e
BS3
^3
E3
10.0
infacOana
Dianhaaai
dHaasa
Maitlat
Itchaamfc
Haart
5-10%
1-5%
0-1%
trend data unavailable
lx'3 outside region
I
MMamil
condWont
<IHaa*a
A
a
A
II lAMM
»**■ U
2
s
Historical Stages of HIV Spread in
Asia and Pacific
Historical Stages of HIV Spread in
Asia and Pacific
• During the 1990s, in several South and South-east
Asian countries (Cambodia, parts of India,
Myanmar and Thailand), significant heterosexual
transmission continued or was first noticed.
• An explosive spread of HIV occurred within IDU
populations (levels of more than 50% within 1-2
years in several provinces of China, north-east
India, Malaysia, Myanmar, Pakistan, Thailand,
and Vietnam, Indonesia, and Nepal.
• During the early to mid-1980s, there was extensive spread
among men who engage in same-sex contact, especially in
Australia, Japan, Malaysia, New Zealand, Singapore and
Hong Kong
• During the mid- to late 1980s, high HIV prevalence was
documented among other populations with high risk
behavior (50% or more among female sex workers in
Thailand and in parts of India, notably Mumbai)
• In addition, at the same time, there was HIV spread among
Injecting Drug Users (IDUs) in Thailand, Northeast India,
and the "Golden Triangle” area of China, Myanmar, and
Thailand
Some HIV/AIDS n Am and the Pmbc Regoa WoM Hee* Ornjotonon. -'CO I
Some HtWAIDS n Aal md the Pacific Regnm. World Headh Oigaatacon. 2001
HIV/AIDS in Asia and the Pacific
HIV/AIDS in Asia and the Pacific
• Almost 1 million people in this region acquired HIV during 2002 - a
10% increase since 2001 - bringing the estimated number of people
• The epidemic in China shows no signs of abating.
• Official estimates put the number of HIV-infected people there at 1
million; there was a 17% increase in new infections in the first six
living with HIV there to 7.2 million.
• China and India are experiencing serious, localized epidemics that
months of 2002.
• The country is marked by widening socioeconomic disparities and
are affecting millions of people.
• Although India's national adult HIV prevalence rate remains at less
than 1%, it has an estimated 3.97 million living with HIV - the largest
extensive migration (more than 100 million Chinese living outside
their home regions) - these factors have strong influences on the
spread of the epidemic.
number in a single country with the exception of South Africa.
A
A
_______
Number of people who died
from HIV/AIDS in Asia: 1980-2001
Number of people living
with HIV/AIDS in Asia: 1980-2001
- 500------
Ii780T"~
'
3 400.......
5.0----------
300
4.0----------
3.0- -.......
200 -
2.0 - -
100........
10----0.0 ■ IT
1983
1980
1988
Swt* UMMOSMM).
•1 Mr an
1989
1992
1995
1998
19M
2001
A
1M3
1IM
A
Sourc* UNMOSMMO. 7a>2
•i Mr an
r—b- asw m
nuMw ASl* u
3
i
HIV prevalence in adults in Asia: 1986-2001
Annual number of persons diagnosed with
HIV and AIDS in Myanmar: 1988 - end Sept 2001
6,000
—.....
5,000
-■iMXDS oa»M delected earli yrai
”
S8S 2 -5%
823 1 -2%
0.5-1%
£3 0.1-15%
ES3 o -0.1%
trend data unavailable g
outside region
4,000 -------------------------------------------3,000
2,000
1,000
j
i
i
i
Tvr"5Trpiii
hm isse «#• r««T
0
IMS IMS WM 1«1 1M2 1M3
e__
A
12,
I
Yaawta
9
6
3
0
1993
1994
1995
1996
1997
1998
-------- I--------1999 2000
A
IMPS Wx—Dana rUlWaUSCiwW—
i
•
m®0 2001
(S«M
»)
A
■*>■
Knowledge about HIV in China
HIV prevalence among sex workers
in selected provinces in China: 1993-2000
GtkJJigxi
a MOS
i
• One in every five Chinese does not know what
AIDS is, according to the government of China.
• The State Commission for Family Planning
conducted a survey of 7,000 people in different
regions.
• 71% of those interviewed did not know how
HIV is transmitted.
• According to the Health Ministry there, some
22,500 people are reported to be HIV-infected
in China, but this number is thought by some
to be as high as 600,000. The government
recorded 466 deaths due to AIDS since 1985.
*o6i*oa
Potential for Increasing HIV Burden
in Asia
% of World’s
Population
Distribution of
Adult HIV
Infection
Asia and Pacific
60%
18%
Sub-Saharan
Africa
8%
70%
Some Causes for Grave Concern about
HIV vulnerability in South Asia
• 54% of its population is under the age of 25 - the age of
vulnerability for risk taking behavior
• There is ample evidence of sexual activity and of injecting
drug use among young people
- in Maharashtra, a study of adolescent, married people
indicated that 48% of boys had engaged in premarital
sex
- in Nepal, HIV prevalence among IDUs increased from
2.2% in 1995 to nearly 50% in 1998
- Thousands of children live and work on the streets many abused, marginalised, unaware of HIV risk
4
I
Scenario of the epidemic in Thailand
had there been no intervention through 2020,
and observed epidemic curve
.......
10,000
1 8.000 -
Success Stories
f 6,000 -
► Wttvertion
o 4,000 .........
f 2,000 ------
e__
A
0
m 1111 r
1985
1990
1 995
r11 ■ i11
2000
0MM. « MOS.
P—c
wyiMcspiM-.— ciiMniwMost»w»—
01 kA
2005
'
2010
2015
2020
S-W mJtn__________
A
M rvA* ASWa
HIV/AIDS in Eastern Europe
and Central Asia
HIV infection in Thailand: 1985-2000
• This region has the unfortunate distinction of having the fastestgrowing HIV/AIDS epidemic. In 2002, there were 250,000 new
infections, bringing to 1.2 million the number of people living with
1400 -------
| 1200 --
HIV/AIDS in this area.
S 1000 ----
I
• The Russian Federation has experienced an exceptionally steep
rise in new infections, mostly due to transmission through injecting
800
600
drug use among young people.
400
• Knowledge and awareness remains dismal among the wider
population, the epidemic is beginning to spread more extensively.
200 ------
1985
1990
1995
2000
2005
2010
2015
2020
A
A
W k.
•i Mr» **
tcrv-va
aoa
«>•
HIV prevalence in adults in Latin America
and the Caribbean, 1986-2001
HIV/AIDS in Latin America
and the Caribbean
• An estimated 1.9 million adults and children are living with HIV in
this region - this includes the estimated 210,000 people who
acquired the virus in 2002.
• Among pregnant women, in twelve countries of the region, there is
an estimated HIV prevalence rate of 1% or higher.
• In several Caribbean countries, adult HIV prevalence rates are
surpassed only by the rates in sub-Saharan Africa - making this the
second-most affected region in the world. Haiti is foe worst affected
in foe region (est. 6% sero-prevalence) and Bahamas has a 3.5%
sero-prevalence rate.
A
EB8 2 - 8%
sa 1 - 2%
Ex3 0.5 -1%
ES3 o.i - 0.5%
o 0 - 0.1%
5553 trend data unaraSabte
outside region
e
A
•l MV MS Ate
lAC-M
»W»«K
unraMtn
5
I
HIV/AIDS in the Middle East
and North Africa
HIV/AIDS in High-Income Countries
• Systematic surveillance is inadequate in this region, so it is difficult
to deduce trends in HIV infection for the area.
• It is estimated that 83,000 acquired the infection in 2002 - bringing
to 550,000 the estimated number of people living with HIV/AIDS.
• Significant outbreaks of HIV infection occurred among drug users in
half of the countries of the region, notably in North Africa and the
Islamic Republic of Iran.
• Other affected groups include men who have sex with men and sex
workers and their clients.
A
• Approximately 76,000 people became Infected dtxlng 2002, bringing to 1.6
million the number of people living with HIV/AIDS In these countries.
• The introduction of antiretroviral therapy since 1995/1996 has
dramatically reduced HIV/AIDS mortality In these countries. About 500,000
people were receiving this therapy by the end of 2002.
• A larger proportion of new HIV diagnoses (59% between 1997 and 2001) in
several Western Europeai countries has been traced to heterosexual
Intercourse.
• Sex between men remains a prominent transmission root; the behavior
change previously accomplished In this population is now a thing of the
Past
A
I
Predictions for the “Second Wave”
of HIV
• Five countries - Nigeria, Ethiopia, Russia, India, and
China - will be burdened with some 50 to 75 million
people living with HIV.
• In Nigeria, life expectancy is expected to decrease to age
47, compared with 61 before the arrival of AIDS; and in
Ethiopia, to 40, from 53 before the onset of disease.
• In addition to the increased health care costs, the
burgeoning number of orphans due to the death to AIDS of
one or both parents, other catastrophes forecast for these
countries by 2010 include:
- famines,
- civil wars
- economic reversals
- collapse of social and political institutions
Political/ technical skills
j
Lack of education
lost
Drain on health
resources
[ Economic Impact |
Human rights 4- | J®
WOMEN: care<::
burden &
vulnerability ■T
Orphans/
street
children
less/ death,
ferty, grief
Changes in life expectancy in selected African countries
with high and low HIV prevalence: 1950 - 2005
kT
Stigma, Isolation
Medical Expenses - > Poverty!
80 - -........
r:
Trauma, bereavement
v;;;::;;:p£HAs relegated to passive rote,
NOT active players
Discrimination, scapegoating, blame
Decreased Life Expectancy
Lost Earnings
It..
w«h Noh HW pravalanm:
•"Da*a»w«
-•-SauOi *rica
•■■Saawwana
wKh l»w HIV provatenc*:
—Madaaaaear
—Samoa!
X
^^0 X— --- ----.r—
A
—-----
---
6
I
-Structural vulnerability (eg. povtrty&mignrt
Impact on Population & Life Expectancy
a
• U.N. Population Division
estimates that the population of the
45 most affected countries will be
97 million smaller in 2015 and
that the world population will be
480 million smaller by 2050.
• India alone will account for 47
million additional AIDS-related
deaths and China will account for
an additional 40 million such
|</ '
deaths.
• Life expectancy in Sub-Saharan
Africa is the same as it was in
tenth century Europe.
work)
- Desperation and high risk behaviors (eg. CSW)
- Lack of access to preventive interventions
- Lack of access, atfoedabdity of care once infected
- Lower educational status ■» leas access to info.
..
Poverty
BOM
-Lost productivity
-Catastrophic costs of health care
-Increased dependency ratio
-Reduced national income
-Orphans with worse nutrition, lower
school cnrollmaS
-Fewer resources for HTV/AIDS control
-Decreased ability to “manage” household
in families headed by elderly, orphans.
The impact of HIV/AIDS on industries:
an overview
Economic Growth Impact of HIV
(1990-97)
Bp
Figure 2: Growth Impact of HIV (1990-97) (80 developing countries)
4 ■—fc—
.
lirnm
■02
■04
n
■0.S
n
|!
Mod
_
4 —ora Mlmn
ZITSZ
-04
•“
4f—
5
W
20
28
KV Praval—ca
18
l*ii
»
&
3S
Mar* RBH^Wfc-^**^**^****^***"** ’
WarMflBBl
AIDS in the family means increased costs,
greater poverty
• A study in Cote d’Ivoire indicated that health
care costs rose by up to 400% when a family
member had AIDS.
• Households in both Thailand and Tanzania
reported spending up to 50% more on funerals
than on medical care.
• Research in Tanzania showed that individuals’
food consumption dropped by 15% in the
poorest households after the death of an adult to
HIV/AIDS.
Sore* UKM>S
gg
n-
w
INUUDS (2SV7> •flllllf Of
f
l«W> l—r—<
Bereavement
Psychological scars
Child-headed households
Less of education
Disinherited
No legal protection
Sex as a survivai/coping
mechanism/source of affection
Loss of role models
No parental protection/care
"W*”. 3DfQ
Boredom/ Alcoholism/ Drug use
Burden of care for sick parents
7
Cumulative number of children estimated to have
been orphaned by AIDS* at age 14 or younger
at the end of 1999
Orphans: A Lost Generation
T
Numbers are large and growing
•
Social support systems are
Eaten Europat
overwhelmed
•
WwtenEwop* CqtMAib
9 000
500 EjrtA,14*p»rfic
North Anwrisa
500
70 000
CartbttMn
Risk of a lost generation:
85 000
- little or no education
- poor socialization
- social upheaval
- economic underclass
Lrfn Anwiw
110 000
NortbAfitoa
IWddUEwt
15000
3 600
South’
7'**
tSdum-EMtA^
850 000
StA-Sateran
Miiot :
12.1
million
Zaaiand
<500
Total: 13.2 million
COXM4 A- trjtf rooo
| HIV inlection |
I
r
,
Children tnay become carrgivernj
“T
1 Increasinrlly serious illness |
I--------
‘l Pbyc
al distress |
Economy problems L
, Oe.nhs ol parents A young children j
J Problems wrthl
I
Children withdraw”
Irxxn school
I
inheritance
r
| Children without adequate adult care |
Inadequate lood
Discrim inaDon
I Problems with shelter j
[
& material need*
j
Exploitative child labour]
[
|
Reduced acceee to
health services
I------[
* Inoreased vulnerability
I
to HIV1 infection
r—
Sexual exploitation
]
Life on the street
|
unteef®
Projected annual expenditure requirements
for HIV/AIDS care and support by 2005, by region
S*uth and SMtwaat
Asia: US$870M(15 08%)
East Asia. PacMe:
UStS0M(l 80%)
Udn Awertu. Caribbean:
USJ55QM (12 39%)
Eastern Em*a. Cantral
AsU: UteM0M(0«%)
Morn, Wrfca. Ml*dl< Else
US$50M(t 13%)
Total: US$4440 mdlion
s«ro fciii.—b»»l«<M»l>A
Sexual
healtfi
services
(education,
prevention, care, treatment,
FGM, MTC, STDs, condoms)
Screened blood/ transfusions
Sterile equipment / needles
Voluntary testing & counselling
T8 treatment & control
Care of people with AIDS
'Basic drugs. ARVs, MTC)
Withholding routine treatments
for people with HIV/AIDS
ed^
Young
people unskilled
and unoccupied
Future micro-a macro
economic Impact
Myths & stigma
Lack of knowledge about
HMAIDS a other STDs
Sex at earlier ages
Pregnancy
(+MTC)
ir I ■■■<■»■ !WiA»«.iaama
8
I
Education systems collapsing ...
• AIDS has an impact on both the availability
and the use of schooling.
• In Central African Republic and Swaziland,
school enrollment is reported to have fallen by
20% and 36% due to AIDS and orphanhood,
with girl children most affected.
• In Guatemala, studies have shown that more
than a third of children orphaned by
HIV/AIDS drop out of school.
Percentage of children aged 10-14 who are still
in school, according to whether their parents are alive:
selected countries, 1997-2001
1
ib
.
.. 8oH> pwvon
* 8Mt* pvrvoa 4c»d (’A)
Smck UMCEF<t*
ihnm Saawya
Some HIVIAIDS
for
JMckx UMed
feme's
ilki
parent (%)
|(1W7 2W1}D»l»W>r
Prow»o
tor a, UN Oeond Aorratlv Sped Sernon on HIV/AIDS. 25-Z7 lor .001
Stigmatization and Marginalization
Loss of Housing
Mandatory HIV Testing:
employment
church candidates
education, visas
Discrimination
• employment, finances,
- social exclusion, family
•health & education access
Confidentiality
etc..
Stigmatization and Marginalization
• Attempts to “cast out” those affected by
HIV/AIDS - from villages, hospitals,
educational institutions, and even faith
communities - have been experienced in all
parts of the world.
• Sadly, some priests and ministers have even
refused pastoral care and church burial to
HIV-infected.
• Many governments have enacted policies of
forced isolation or restrictions of travel by
HIV-infected.
• Studies in Cote D’Ivoire and South Africa show
that, in places with extremely high HIV
prevalence, women refused testing or did not
return for their results.
• In southern Africa, a study on needle stick
injuries found that nurses did not report the
injuries because they did not want to be tested
for HIV.
• In a study on home-care, fewer that 1 in 10
people caring for an HIV patient acknowledged
the disease affecting their loved one.
Pope John Paul II on acceptance of people
living with HIV/AIDS
“God loves you all, without distinction, without
limit. He loves those of you who are elderly, who
feel the burden of the years. He loves those of you
who are sick, those suffering from AIDS. He loves
the friends and relatives of the sick and those who
care for them. He loves all with an unconditional
and everlasting love.”
Given M Mission Dolores. Sal Frmcisco. CA (1989)
9
i
Privacy, Confidentiality, and Responsibility
Rights to Privacy and Confidentiality
• Many people, including some clergy, have the
false concept that HIV could be spread by casual
means and think that HIV-infected need to be
publicly identified in order to avoid infection.
“Every precaution should be taken to protect the
confidentiality of records, files and other
information about the HIV status of
• Instead of adopting “universal” health care
precautions - valid preventing spread of HIV and
other blood-borne diseases, some health care
workers think that HIV patients require special
precautionary measures and thus disregard the
patient’s right to confidentiality.
employees.” neMlaVFam<^An>S.-A Go^elResro^, U.S. CMhoHc
Bhlwpt' Adml»tatr*tiv» Baard. 1987.
“No one may unlawfully harm the good
reputation which a person enjoys, or violate the
right of every person to protect his or her
privacy,
./g—«».
Women severely affected...
Rape
Gender Inequality
HIV as a weapon of war
Knowledge & attitudes
Financial dependence
Lack of Legal Power
Biological, physical & social
vulnerability
Main Care Prowlers,
regardless of cost to self
Percentage of 15-19 girls
who do not know that a HIV-infected person
may look healthy, 1994-1999
I“
1"
« 70
i “
uiuiij
h
• They are more likely to be poorly educated and
have uncertain access to land, credit, and
education.
• Women-headed households are poorer and
have less control over productive resources.
ImphaaaBfar Pmw .■tadeaaa Uoaod Nana C>cvriop™« Prosran Badcgnani Papa prrpatd
Sourer HIVU1DS
/
«’to UN Crncrd Aaanbl, Special SeaaM «> HIV/AIDS. H-Tt June 2001
far
Percentage of 15-49 year old women
who are aware that HIV can be transmitted
from a mother to her child, 1994-1999
Zla<bab««
ZimW*
•
Ug«r>4i
■
Kanp
SauthMMn
■
■
HaM
' a
TaraarJ
a
CARa
1
■
Cota fkalra
a
Cwru *h
Ma4a«Mcar
■
■
' ■
MaN
' a
Chad
■
Mfar
'
z
• Women are more vulnerable to HIV/AIDS
because they have less secure employment,
lower incomes, less access to formal social
security, less entitlement to assets and savings,
and little power to negotiate sexual contacts.
4^
f f
Samaic Umar, Otaimim •» wvfl*
tarac UMCM. OHS
■
10
I
Pope John Paul II, in his Apostolic Letter,
Novo Millennio Ineunte, at the close of the
Jubilee Year 2000:
“Our world is entering the new millennium
burdened by the contradictions of an economic,
cultural, and technological progress which
offers immense possibilities to a fortunate few,
while leaving millions of others not only on the
margins of progress but in living conditions far
below the minimum demanded by human
dignity. How can it be that even today there are
still people dying of hunger? Condemned to
illiteracy? Lacking the most basic medical
care? Without a roof over their heads?”
Archbishop Javier Lozano Barragan
continued...
“An important factor contributing to the rapid
spread of AIDS is the situation of extreme
poverty experienced by a great part of
humanity. Certainly a decisive factor in
combating the disease is the promotion of
social justice, in order to bring about a
situation in which economic consideration
would no longer serve as the sole criterion
in an uncontrolled globalization.”
i|he Global Fund to Fight AIDS, Tuberculosis
tind Malaria
Church looks at both individual
and social values
Statement of Archbishop Javier Lozano Barragan at
UN Special Session on AIDS July 2001:
“In many cases, HIV/AIDS implies problems also at
the level of existential values; it is true pathology
of the spirit which harms not only the body, but
the whole person, interpersonal relationships and
social life, and is often accompanied by a
moral values.”
a
’ We just have to do some
simple math to save the
developing world!
Macroeconomist, Jeffrey Sachs, says that
we could fight malaria, TB, and HIV, by
providing medications, technology, and
prevention funding to the poorest
countries with onlv $27 billion per year;
that is 1/1000 of the income of the “rich
countries.
• Sachs maintains that we could save 8
million lives per year if the “rich world”
were willing to set aside 10 cents on every
$1000.
The Global Fund to Fight AIDS, Tuberculosis
and Malaria - Progress to Date
■ $866 million awarded over a two-year period
• ; ■ To help fight the 3 diseases in 60 countries
■ 60% of the money will be used to fight
HIV/AIDS
■ This will enable a 6-fold increase in the
number of people in Africa being treated with
combination anti-retroviral medications
■ Thus it will ensure that more than 500,000
people in developing countries can have
access to such medication.
11
f
Four factors underpin access to essential
drugs- money is involved in each
'9
Major Learnings at Present Stage of
Pandemic
• The HIV/ALDS pandemic is still at an early
development and its long-term evolution is still unclear.
1. Sustainable /'
financing
I
"Lu""
W
• Some success in prevention activities (e.g., in Thailand
and Uganda) has been achieved in particular countries
- usually this has happened with a multi-sectoral
approach and with active involvement of young people.
ACCESS
i
4,
>
heolth systems:
(Frwity setting/
/ratmnd setectkm
-y..... ___________
• A necessary component in this success has been
community mobilization, including elimination of
stigma, partnership between government and others in
the community, and involvement of all sectors in the
community.
WHO - EMt
«7
S<«M<e UNADS Banttmi .W Rn«x1
Major Learnings at Present Stage of
Pandemic
Access to comprehensive care and treatment for
HTV/AIDS is not an optional luxury in global responses
- this must be made available in all parts of the world.
It is crucial to address the economic, political, and
cultural factors that render individuals and
communities vulnerable to HIV/AIDS.
• While the lack of capacity and infrastructure must be
addressed in developing countries, it should not be an
obstacle to making comprehensive care and prevention
available in all countries that show a commitment to an
expanded response.
H•
I I
>
•
12
J
J)l S
CHAI’s Effort to Deal with HIV/AIDS
Introduction about CHAI
The Catholic Health Association of India (CHAI) is one of the world’s largest non
governmental organization in the health sector with about 3080 member institutions,
which include big, medium and small hospitals, health centers and diocesan social
service societies is fifty eight years old.
The members of the association extend health care facilities to the poor and the
marginalised. These members are located in various parts of the country - urban, semiurban, rural and tribal settlements. The member institutions are predominantly engaged
in providing preventive, curative and promotive care.
The main thrust of CHAI was promotion of Community health for nearly two decades
now. During the Golden Jubilee year CHAI evaluated its impact and brought out direction
with which it has to be proceeded in the future. The priorities identified in the evaluation
icluded reemphasizing the importance of promoting community health, decentralization
of the organizational responsibilities towards its member institutions, continuing medical
education with special emphasis on HIV/AIDS and Communicable Diseases.
Involvement with HIV/AIDS work
As HIV/AIDS was becoming a serious health and social problem, there was an urgent cry
from all quarters of the church to respond to this grave situation. Since CHAI is the
structural body responsible for health, everyone looked up to CHAI for guidance and
direction on HIV/AIDS.
Milestones of CHAI’s growth with specific focus on HIV/AIDS
1993
AIDS Desk was formed
“Think-tank” group
1994
CHAI’s Policy on HIV/AIDS
1995
CHAI'S Plan on HIV/AIDS
1996-1997
Personnel from the member institutions were trained to plan
and initiate actions in their regions
1998-2001
-Developed human resources in care and support
-Networking with like-minded organizations for
lobbying and advocacy.
2002 - 2004
policy
The quality of life of the persons infected and affected with
HIV/AIDS is enhanced through a process of specific
interventions such as implementer's forum and promoting
access to parallel system of medicine.
Specific Areas of Involvement
CHAI approached the situation at various levels
Prevention
Training health
professionals
Thrust Areas
care
and
social
care
Networking
Policy
Continuing Educational Material
Prevention
Prevention had been an utmost concern. CHAI had done pioneering
work in the area of school health. Developed modules and
innovative approaches for Life Skill Education in schools ad
colleges with the collaboration of CRI in 1997- 1999.
Now we have been invited by Andhra Pradesh State AIDS Control
Society to be the nodal agency for the school health programme in
the state of AP for the non-govemment schools.
Training
Training of the health care personnel with specific skills on
prevention, counselling, care and management. About 650 persons
have been trained and about 50% of them are directly involved in
giving care while others have initiated activities along with their
ongoing work.
Training Programmes &
Participants trained
Short Courses
25%
Care &
Management
7%
Counselling
14%
Policy
36%
Skills in care
18%
/
Networking
Networking with church related institutions, NGOs and
Government agencies - such as APSACS for the school health
programmes “Life Skills Education” and Drop-in Centers”.
TB and Malaria Control Programme through the regional units.
Training on microscopy through Government agency.
Collaborating and networking with other Churches for care and
prevention - Community Health Watch Groups.
Policy
Consultations were organized at Regional and National level to form
policies
Common church policy
Intensive efforts had been taken to network and collaborate with
church bodies, church related institutions and NGO’s to bring out a
common church policy on HIV/AIDS.
Prevention, care,
management, counselling and training of personnel. This policy
would be available in six months.
2. Congregation and institution policy
Policies to be made flexible to ensure that persons infected and
affected are cared and supported. Consultations and discussions
with 212 decision and policy makers of the member institutions were
organized.
(St. Ann’s of Luzen sought help in developing the policy and now
they have started a center in Vijayawada, Andhra Pradesh for both
men and women with HIV/AIDS).
Continuing Educational Material
Through our interventions, there was a felt need for scientific and
updated information among our membership. Personnel who have
been trained by us are updated with the recent developments with
continuing educational material on HIV/AIDS and the concerns and
issues. This material is sent once in four months.
Impact
Nine years into HIV/AIDS work - we stop to look back and see if we have made a dent in
the epidemic. Has our mission of Christian love reached to the forsaken one?
We feel content enough to say YES!! We made a dent in this epidemic through our love,
service, and efforts.
The approaches and strategies used during the past nine years in the areas of
prevention, training, networking, impact on the policies, and disseminating information
enabled us to be instrumental in starting 35 organizations/ institutions in India for the
care, support and management of persons infected and affected with HIV/AIDS.
Organisations working for HIV/A1DS
Research
Oraganisation
3%
Children
Hospitals
23%
Hospice
48%
Integrated
Approach to
HIV&TB
6%
\
Community
Based
Approach
11%
Back in 1993 when the challenge of HIV/AIDS was hurdled at us, there was not even a
single church related institution for the care and support of these most neglected and
rejected ones. But today we are glad to see 35 institutions giving these services. One
young sister from Mumbai says that she feels it is enough if we can allow them to die in
peace and dignity.
Institutional care has always brought criticism about the sustainability, feasibility and
impact in the long run. However, when we look closely we found the impact the
institutions have made:
x The institution facilitates acceptance in the community
The local community contributes in caring for persons with HIV/AIDS through
volunteering to serve or meet their needs. Thereby through this process remove
stigmatization.
The organization facilitates to build back the lost relationships of the persons with their
family and community.
Promotes dignity of life.
The experiences shared by our member institution working with HIV/AIDS have
shown that institution/ organizations are instrumental in fostering community support
in the course of time. ( eg. Jyothi Terminal Care center)
The membership involved in HIV/AIDS works were initiated based on the needs of the
people. The situation differs from state to state thus each organization is a unique model
by itself. Some of them focus on children while others care for men and women.
Few approaches that have made difference.
Integrated Approach
Mukta Jeevan now has an integrated approach to communicable diseases. The pioneer
institution by sisters of Helpers of Mary in Thane was started for the Leprosy patients.
After the outbreak of HIV/AIDS as some of patients also are with HIV. The management
inmates who live as a family there. There are men, women and children with and without
infections.
The families are supported to earn their livelihood through various income generation
programmes. The children are sent to the local schools.
Community Involvement
Jyothi Terminal Care Center - A hospice was started two years ago in Mumbai has about
40 inmates. There was a stiff resistance from the local community. They have even
requested the hospice to be shifted. However, over a period of six months, the
community observed that the patients were cared by the caregivers without fear or
stigma. The carers also started going into the community and sensitizing them. The
response was overwhelming.
The organization is now run solely on local contribution, which even includes food,
clothing and medicine. The local community takes care of the dead. They perform the
last rites according to the patient's wishes. The women folk of the community volunteer
their services in the kitchens. A place, which was started as a hospice, has generated
such a large community response.
Implementers Forum
A forum of organizations is envisaged at regional level of the members involved in
HIV/AIDS related work. The main aim of the forum is to:
Training and enhancement of skill development
Establishing linkages/network with others working for HIV/AIDS
Collaborate for specific issues such as gender sensitivity, care and support
Updating and sharing of resources - material and man power.
Support and care of the caregivers.
Some of our learning and challenges over the nine years are:
• As India is a vast country having different cultural, the problems presents and the
approach needs to different.
• A significant finding is that the training programme enabled the members to address
the concerns of the HIV/AIDS.
• There has been an attitudinal change among the membership and a considerable
shift in the policy regarding admission for treatment.
•
Some of the membership has made a shift from institutional care to community based
care, which is foreseen as a positive development towards the mainstreaming of the
persons infected and affected with AIDS.
New initiatives
>
Based on our learning, the new initiatives envisaged are:
>
Implementers forums
>
Integration of HIV/AIDS to communicable diseases
>
Research and promotion of parallel system of medicine
>
Training on care and management
>
Research documentation
Through the initiatives
We hope to evolve care and support from the community-based
organization and providing basic care and counselling at home.
To establish much stronger network with national and international
agencies working in this field to mobilize a massive effort against HIV/AIDS
to meet this challenge adequately, efficiently and effectively.
Church’s Response to the HIV/AIDS Pandemi^
A Collective Catholic Action Against AIDS - A Proposal
Bishop Bernard Moras
Bishop ofBelgaum
Chairman. CBCI Commission for Health
Welcome!
We are aware of the multifaceted faces of HIV/AIDS
It is spreading with unprecedented rapidity
It has devastating effects on the entire fabric of our society
- More than just a medical issue, it is a social, developmental & humanitarian
issue
- We are aware of the combined efforts in other parts of the globe, especially by
the Govt., the Church and other faith-based groups and NCOS'
- The Church in India is involved in the prevention and care to a great extent
-
But, now it is the most appropriate time to think together to design a strategic
plan for a concerted action, as HIV/AIDS cases are rising at an appalling
speed
-
1. OUR PERSPECTIVES
1
The Christian commitment to serve the sick has its mandate from Christ, the
Divine Healer. (Lk 9:1; Mt 10:1). It is a call to serve with the same love and
compassion of Christ in front of human suffering (Cf. Mk 1:41; Mt 20:34). It
is a commitment to continue the action of Jesus, who came to give life and to
oive it in abundance (Cf. Jn 10:10). Our involvement m healthcare is Clmstcentered and derives its inspiration and guidance for values and action from
Jesus, the Master.
2. Service to the sick is an integral part of Church’s mission (Cf Dolentium
Hominum, n.2). Our care, compassion and love towards those affected by
HIV/AIDS are the expression of our faith in solidarity with them in their pain.
Our service to them and to the members of their family is our genuine
response as they are our sisters and brothers in Jesus the Lord, who is present
in those who are suffering (Cf. Mt 25:45). ‘ffhose suffering from HIV/AIDS
must be provided with full care and shown full respect, given every possible
medical, moral and spiritual assistance, and indeed treated in a way worthy of
Christ himself’ (Pope John Paul II).
3. Our approach is guided by a precise and all-round view of human person
“created in the image of God and endowed with a God-given dignity and
inalienable human rights” (Ecclesia in Asia, 33). We do not approve any sort
of discrimination or hostility directed against persons with AIDS, which is
unjust and immoral.
1
4. What we aim is a collective response and an inter-sectoral approach. The,
Church is called to collaborate with national and state governments,
international agencies and NGOs, in addressing the issues pertaining to
HIV/AIDS. In our interventions we will adhere to the moral teachings of the
Church.
5. Though we continue to concentrate on care and support of those infected by
HIV, our priority will be the preventive approach with community
participation. So/ health education, awareness building, campaign for
prevention, teaching of values for behavioural change etc. will be our strategy.
2. RELEVANCE OF OUR CONCERTED ACTION
i.
ii.
iii.
iv.
v.
Magnitude of the issue: Urgency, Prevalence of the Pandemic
The gravity of the pandemic is still not properly assessed and understood
Limitation of the existing isolated, diversified interventions
Our personnel and facility is remarkable, yet not well coordinated, not
sufficiently united
We need to have a common agenda, plan and policy
Therefore,
1. Intensification of our involvement,
2. Functional programme, system and structure
3. Coordinated, combined, scientific, collective and intensive intervention
3. HOW TO ACHIEVE THIS?
1. Intra-coordination
- Actors within the Church
2. Inter coordination
- Actors other than the Church
4. OUR STRENGTH
National and 12 Regional Episcopal Bodies
CBCI Commissions like Health, Youth, Women & Education ft
National Organizations / Associations
Developmental: CMMB, Caritas India, CRS, IGSSS, etc.
Health: CHAI, CNGI, SDFI, etc.
Religious: CRI
Social: ICYM, AICUF
Academic Medical Faculties
St. John’s, Fr. Muller, Pushpagiri, Amala
112 Nursing Schools
Diocesan
148 dioceses /12 Regions
- Parish level
f otao
- Health / Educational / Social Institutions
$2%
100 Seminaries
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7
-
2
2-o
1
5. AREAS OF INTERVENTION
A. Prevention
1. Facilitate a movement to address the issue
2. Awareness campaign in parishes, health and education institutions
3. Education for Prevention, esp. training in the authentic values of
life, love and sexuality
4. Blood Transfusion
5. Issues like needle sharing, drug addiction
6. Prevention of Mother to Child transmission
B. Care and Support
1. Home-based / community care
2. Institution based
3. Care of care givers
C. Rehabilitation
D. Research
E. Addressing social issues: stigma, discrimination, misconceptions
6. FINANCE
Mobilisation of funds
j .u Financial support: Govt, resources, NACO; CMMB, Caritas, IGSSS and other
organizations; local resources.
One Sunday collection can be devoted to this cause. A request can be made to
the CBCI for this.
7. APPROACHES
1. Inter-sectoral
2. Advocacy and net-working
3. Collaborative
1. Inter Sectoral
-
-
Greater involvement and participation of the church and church-related
organizations and institutions in tackling the problem of HIV infection and
AIDS in the country.
Institutions of Communication, print and electronic media to involve in
campaign and awareness building.
-
To build linkages at all levels for overall support in enhancing the quality of
life for people infected and affected with HIV/AIDS.
-
Situating HIV infection and AIDS in the context of comprehensive health of
the people and the emerging and re-emerging infections.
3
2. Advocacy & Net-working
1. Motivate different groups in the church to participate in these activities i.e.
CRI, Religious Congregations, Parishes, Social work organisation .
2. Network with others to form a Forum
3. Training and Re-orientation
4. Bring together practitioners at regional levels to reflect & design follow up
5. The policy of the Church developed could be integrated with other
commission in the Church (Commission for Education; Youth; Women etc.)
6. Church could take initiative on education and health ministry' regarding
HIV/AIDS related awareness to Church personnel and at parish level.
7. No church organization should close its doors to HTV/AIDS affected persons
8. Need to educate for community / home based care.
9. During formation, exposure program to Novices in the institutions where
caring for HIV/AIDS patients should be part of their experiences.
10. Lobbying with the Govt and other agencies to put pressure on the
pharmaceutical companies for the availability of high-cost patented medicines
at a cheaper rate to the HTV/AIDS patients.
g C H fl T'
3. Collaboration
- To collaborate/network with State AIDS cell
- District health action forum to address on HIV/AIDS
- The Rel. Congregations involved in HTV/AIDS program to network with others.
- Basic Christian communities and basic inter religious communities - to
forum for information, dissemination as well as health activist network at different
level with NGOs and GOs.
8. STRATEGY
1. A National Coordination Team
2. Finalisation of a National HIV/AIDS Policy
3. Collaboration with international & national agencies in intensification of our
involvement in prevention and care
4. Provide support in HIV/AIDS awareness programmes for school and college
students and communities. Promotion of increased scholastic and
extracurricular education about values of life, love, sexuality and family,and
elimination of all forms of discrimination of people suffering from HIV/AIDS
5. Encouraging Dioceses/Religious Congregations/NGOs to open Care and
Support Centers; programmes to protect of AIDS orphans and to give attention
to the vulnerable groups.
6. Equip the Catholic healthcare network to offer quality treatment tor
opportunistic infections
V
131
-
4
r,
Conclusion
Statistically 12% of those providing care to HTV/AIDS patients worldwide are
agencies of the Catholic Church, and 13% are Catholic non-governmental
organizations. The Catholic Church is thus carrying out 25% of the total care given to
HIV/AIDS victims, which makes the Church the major supporter of States in the fight
against this disease. (Cf. Archbishop Lozano’s speech at UN’s XXVI Special General
Assembly on HIV/AIDS, New York, June 27, 2001).
Christians in India are a tiny minority community, just about 2.3% of the total
population. Yet, the contribution of this miniscule community in health, education and
social service is remarkable and effective. In the fight against HIV/AIDS, the Church,
though involved to a great extent, it has a major mission to achieve. Considering the
magnitude of the HIV/AIDS pandemic, the entire Christian community needs to be
motivated and mobilized for which a concerted action and collective response is
imperative.
The Statement of the United States Catholic Conference, “The Many Faces of
AIDS: A Gospel Response” concludes like this: “Our response to the needs of those
persons with AIDS will be judged to be truly effective both when we' discover God in
them and when they, through their encounter with us, are able to say: “In my pain
fear, and alienation, I have felt in your presence a God of strength, hope, and
solidarity”. By the grace of God, may this happen soon!” For the Church in India too
this is a mission and a challenge today.
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A COMMON POLICY STATEMENT OF CHURCH IN INDIA
ON HIV/AIDS
PREAMBLE
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The Cathoiic Church in India is concerned at the alarming increase in the
incidence and prevalence of HIV infection in India. The Human Immuno
Deficiency Virus (HIV) is a blood borne virus that can cause AIDS (Acquired
‘
’. Fifty percent of people living with HIV will
Immune Deficiency Syndrome).
develop AIDS within two to ten years of becoming infected. It is expected that
ninety nine percent will eventually develop AIDS while there are treatments for
opportunistic infections. There is no cure for the HIV virus. There is currently no
effective vaccine against this virus.
The personal and social implications of HIV are significant and cannot be
ignored. This policy has been made to address the implications of HIV/AIDS for
Cathoiic Church bodies in India especially with regard to health care services.
This policy is the outcome of a series of consultations and dialoguesjointly
organised by the CBCI health commission, Catholic Health Association and St.
John's Academy of Health Sciences and wider discussions with other church
bodies.
As a Catholic body the Catholic Bishops Conference of India (CBC!) has
developed the policy on the foundation of the Gospel and Catholic Traditions.
This policy is presented as a guide to all Catholic health care service, teaching
and research institutions in India.
In developing this policy CBCI has been especially guided by the principles of the
church's social justice teachings and statement by the Holy See, Catholic
Bishop's of India, other pastors and teachers / experts in the church.
The dignity and uniqueness of person created in the image and likeness of
God (Ge. 1/1)
> The equality of all people as children of God (Gandiem et spes)
> The Christian acceptance of responsibility for the self, each other and service
for the God of All (G.S)
,
>
J 41^ v .
•
This Espouses a Truly Christian Response.
A Christian Response to HIV/AIDS is based on truth and love. When truth is
embraced, courage and balance prevail: When love is embraced our response is
characterized by compassion and care for all.
This policy calls upon All Catholic health care institutions to implement such a
Christian response to HIV/AIDS and so promote justice and the dignity of the
human person.
The policy provides guidelines for the implementation of sound standards and
procedures. In prevention, care, testing, treatment, management, advocacy and
networking, with all people and associations of good will.
. p.
HiV/AIDS iN iNDiA:
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Introduction:
*?
In India the pandemic of the Acquired immune Deficiency Syndrome (AIDS) is-in
its second decade. According to the estimates of the World Health Organization
(WHO), at least 16 million people are infected by the Human Immune Deficiency
Virus (HIV') and 4 million people have developed AIDS worldwide. The infection
is spreading unchecked.
Some characteristics:
* The pandemic is accelerating in South and South East Asia.
* The infection affects everyone; the people most at risk are the socio
economically poor.
* HiV/AIDS could cause modern economic underdevelopment.
* Women and children are increasingly bearing the brunt of AIDS.
« No cure is in sight; the possibility of a vaccine is also remote.
« Heterosexual transmission accounts for at least 75% of HIV infection in
adults across the world.
* Prevention requires behavioural changes. Being essentially a sexually
transmitted disease, prevention requires change in sexual behaviour.
HIV/AIDS A Priority Focus?
Is AIDS a priority in India? Yes, it is. Out of the 16 million persons infected
globally, more than 2.5 million are in South and South East Asia. In recent times,
there has been a marked increase in the number of infected persons in India. If
transmission of HIV continues at the same pace as at present, by the year 2010
AD, about 8 million persons would have been infected in India; the number of
persons with AIDS would exceed one million
India has the burden of malnutrition, tuberculosis, diarrheas and other infectious
diseases.
AIDS deaths are additional.
The combination of AIDS and
tuberculosis is fatal. AIDS hits those in the prime of life, leaving families
economically and psychologically wasted.
HIV/AIDS IN INDIA
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HIV/AIDS is a global pandemic which is unproved in human history. The people
with HIV/AIDS, by the way they are treated and regarded have become the
equivalent of the lepers of former times. In the gospels, Jesus not only physically
cured the ten lepers and the paralytic, and the women with the hemorrhage, but
he also restored to them their human dignity, and their rightful place in the
community. St. Francis of Assisi and St. Catherine of Sienna kissed the lepers
sores not simply because they were sores but because they were the living
wounds of sufferings of Christ.
For those of us who are dedicated to the service within the Christian community,
it is especially important not to become paralyzed by fear in the face of this
disease, nor polarized in sterile debate. We should instead perceive the
pandemic as a crucial moment in the world's history, when the church can once
again respond to fresh challenges and opportunities with unselfish love and
without prejudices in the footsteps of Jesus our Mother. This echoed in Pope
John Paul 1! speech in Arizona, USA “Today we are faced with new challenges,
new needs. One of these is the present crisis of immense proportion, which is
that of AIDS. Besides your professional contribution and your activities towards
all affected by this disease you are called to show love and compassion of Christ
and his church.”
To respond with love and compassion, with commitment and determination, with
integrity and humility to people with HIV/AIDS must be an intrinsic element of our
preferential option for the poor today, in many of our communities people with
HIV/AIDS are the excluded poor, the poorest of the poor; they are marginalized.
To share, and truly share the concerns of the marginalized always require both
courage and great discernment. First we must understand HIV/AIDS is not
Africa's disease, nor the homosexuals nor the drug users, nor the prostitutes
disease, but a human tragedy affecting people of every gender, race, age group,
sexual orientation, marital status or state of life, babies, high school students,
army officers, married women and men, catholic priest and religious, protestant
pastors and are in danger of dying today of HIV/AIDS and AIDS related
conditions. Whether they contract it from blood transfusions from sexual
intercourse, from mother to child in the womb, from sharing syringes, or from
dirty hospital equipment, they are all to be loved and embraced unconditionally
and non judgmentally as sons and daughters of our God.
It is time for the entire church, bishops, priests, religious and people of God, join
hands to make efforts for its prevention and control. It is time for the Christian
teachers and leaders to educate our people a way of life that is most likely to
protect them from HIV infection. It is time for us to show compassion and love to
those already infected. It is time for us to know to fight this disease while taking
care not to fight the infected. It is time for us to learn to take care of those
infected and help them to live positively with HIV/AIDS. it is time for us to follow
the footsteps of Jesus and walk an extra mile (Mt.5.4) along the infected. We
cannot stand still and stare but act/respond with love and compassion, with
commitment and determination, with integrity and humility to people with .
HIV/AIDS.
o
\\CHAINPemaHin\CD-CME\churchpolicy.doc
3
CHURCH’S RESPONSE TO HUMAN TRAGEDY
i
The church in India has always considered health care as one of her major
apostolate. The special mission to heal the sick and comfort the sick” is clear for
her presence in the health care sector of the country through 4967 hospitals
(includes health care centers) 62 nursing schools 1981 rehabilitation centers and
3 medical colleges and through many other health initiatives both formal and
informal especially community health programmes
The service rendered through the number of institutions in specialized service
sectors like Leprosy relief and rehabilitation units, centers for the disabled
persons, hospices for terminally ill and now many new centers for the HiV/AIDS
patients etc. Is not worthy. The church has a great share of the nations health
care facilities.
~
THE
INVOLVEMENT
ASSOCIATION
OF
CATHOLIC
HEALTH
CARE
As HIV/AIDS was becoming a serious health and social problem, there was an
urgent cry from ail quarters of the church to respond to this grave situation. Since
The Catholic Health Association of India (CHAI) is the structural body responsible
for health, everyone looked up to CHAI for guidance and direction on HIV/AIDS.
Milestones of CHAl’s growth with specific focus on H1V/AIDS
1993
AIDS Desk was formed
“Think-tank” group
1994
CHAl’s Policy on HIV/AIDS
1995
CHAl’s Plan on HIV/AIDS
1996-1997
Personnel from the member institutions were trained
to plan and initiate actions in their regions
1998-2001
-Developed human resources in care and support
-Networking with like-minded organizations for policy
lobbying and advocacy.
2002 - 2004
The quality of life of the persons infected and
affected with HIV/AIDS is enhanced through a
process of specific interventions such as
implementer’s forum and promoting access to
parallel system of medicine.
WCHAINT\emailin\CD-CME\churchpolicy.doc
4
Specific Areas of involvement
1
i
CHAI approached the situation at various levels
Prevention
Training health care and social' care
professionals
Thrust Areas
Networking
Policy
Continuing Educational Material
Prevention
Prevention had been an utmost concern. CHAI had done
pioneering work in the area of school health. Developed
modules and innovative approaches for Life Skill Education
in schools and colleges with the collaboration of CRI in
1997-1999.
Now CHAI has been invited by Andhra Pradesh State AIDS
Control Society to be the nodal agency for the school health
programme in the state of AP for the non-government
schools.
Training
Training of the health care personnel with specific skills on
prevention, counseling, care and management. About 650
persons have been trained and about 50% of them are
directly involved in giving care while others have initiated
activities along with their ongoing work.
Training Programmes &
Participants trained
Short Courses
Policy
36%
25%
Care &
Management
7%
U
. • 41. ».4 .«r
Counselling
14%
WCHAINT\emailin\CD-CME\churchpolicy.doc
^4^ i-u,
u u 4-1». 44.
v
Skills in care
18%
Networking
Networking with church related institutions, NGOs and
Government agencies - such as APSACS for the school
health programmes “Life Skills Education” and Drop-in
Centers". TB and Malaria Control Programme through the
regional units. Training on microscopy through Government
agency.
Policy
Consultations were organized at Regional and National level
to form policies
1 .Common church policy
Intensive efforts had been taken to network and collaborate
with church bodies, church related institutions and NGO’s to
bring out a common church policy on HIV/AIDS. Prevention,
care, management, counseling and training of personnel.
This policy would be available in six months.
2.Congregation and institution policy
Policies to be made flexible to ensure that persons infected
and affected are cared and supported. Consultations and
discussions with 212 decision and policy makers of the
member institutions were organized.
CHAI has helped some member institutions in developing
specific policy for their institutions.
(Other Church Bodies Involvement in the area of HIV/AIDS
could be added; like the CNGI, St. Johns Medical College,
and CBCI - IGNOU etc)
THE MAJOR THRUSTS OF THE CHURCH IN ADDRESSING THE
HUMAN SCOURGE
1. Prevention
5. Networking
3. Rehabilitation
2. Care
6. Living Positively.
4. Advocacy
1. Prevention:
Prevention is the best cure. This is an old adage, which is invaluable in the
area of HIV/AIDS. In fact so far prevention is the only cure for HIV/AIDS.
There is as yet no other remedy for it.
WCHAINT\emailin\CD-CME\churchpolicy.doc
.3
■i
The Three Major Mode of prevention is possible for each mode of Transmission
by using the correct method of prevention.
.•j
* Sexual
Parental (Blood Borg)
# Perinatal (Mother to child)
Methods to Prevent HIV/AiDS Transmission:
Prevention of HIV/AIDS cover 4 broad aspects:
1.
2.
3.
4.
5.
Awareness Campaign
Infection Control
Lifestyle Education - sexual abstinence before marriage
Safe Blood
Mother to child transmission
1, Infection Control
All health care givers adopt universal precautions as pe6r NACO & WHO
guidelines.
'
2. Life Style Education:
Al! health care providers and institutions shall inculcate a healthy life style in their
clients emphasising the following areas:
a.
b.
c.
d.
e.
f.
g-
Nutrition and diet
Exercise
Stress and anxiety
Mental health
Drugs and dependence patterns
Injection practice -use of staff/sterilised/disposabie equipment
Sexual practices: Safe sex within marriage if not abstinence is the best
method. The best policy is sexual abstinences before marriage and fidelity
in marriage.
3. Safe Blood:
Only HIV free blood should be used for transfusion, organs for transplantation
also should be free of HIV contamination.
4. Awareness Campaign:
I
Ongoing awareness through talks, mass media, discussions, lectures, etc. all
church institutions, parishes, village communities and NGO sectors could be
undertaken.
WCHAINT\emailin\CD-CME\churchpollcy.doc
7
■i
5. Mother to Child Transmission:
HIV/AIDS positive mothers are recommended to avoid pregnancy. In case
one is pregnant, the HIV Positive mother should continue her pregnancy and
do not opt for abortion, because about 65% of the children are known to
survive the risk of getting infected with HIV/AIDS. HIV positive mother should
opt for caesarean because through normal delivery a child has every chance
to get infected during the process of delivery. HIV/AiDS mother may avoid
breast-feeding
TESTING:
In testing on HIV/AIDS, all church institutions shall follow the National AIDS
control programme (NACO) guidelines.
i.
No individual should be made to undergo a mandatory testing for HIV.
ii.
No mandatory HIV testing should be imposed • as a precondition for
employment or for providing health care facilities during employment.
iii.
In case a person likes to get his HIV status certified through testing all
necessary facilities should be given to that person and results should be
kept sirictiy confidential and should be given out to the person and with
his consent to the members of his family. Disclosure of HIV status to the ;
v
spouse of the person will entirely depend on the person’s willingness to [iv-v -.
share the information. However the person should be encouraged to^Jiv^
share this information with the spouse and family as it helps the person
in getting proper home based care when he is afflicted with AIDS.
iv.
In case of marriage, if one of the partners insists on a test to check the
HIV status of the other partner, the contracting party to the satisfaction of
the person concerned should carry out such tests.
CARE: There is no cure, yet no limit to care all patients should be given
adequate care and emotional support visiting our institutions.
A. Institutional Care:
□
□
□
□
□
i
Christian Institutions should be visible manifestations of God’s Love.
Ail members of health care institutions recognise their obligations to render
all possible and adequate care to every patient. There will be no
discrimination on the basis of HIV status in matter admissions and
treatment
Our hospitals are encouraged to establish diagnostic facilities, which will
include those for testing for HIV and STD.
Our health care institutions will provide health care services social and
counselling support and spiritual and pastoral care to the people with
HIV/AIDS. Every hospital will have at least one trained counsellor.
All catholic health care institutions will take adequate infection control
measures (universal precaution) to the extent possible.
WCHAINT\emailin\CD-CME\churchpolicy.doc
8
□
/-J
Each institution will have a designated person as contact/liaiSon person for
all matters connected with HIV/AIDS. Larger institutions and dioceses will
have HIV/IDS committees.
B. Home Based Care
This is an integral part of caring. It is needed v/hen the individual has developed
AIDS or even during A^bout of opportunistic infection. Family members or any
one available provides Home-based care. Home-based care includes treatment
of common symptoms such as fever, diarrhoea, cough and other health problems
related to HIV/AIDS. It is basically pa
p; Native in nature and includes maintaining
proper nutrition and patient hygienet
'
families and care givers at home. Need to
be trained in day-to-day care of the p^ient.
oatient. The training
trainina should
should include
include such
such as
planning a balanced diet, principles of hygiene, disposal of
linen etc.
C. Community based care
As there is no care yet for HIV/AIDS, the only treatment is for opportunistic
infection, which all catholic health care facilities will extend to HIV/AIDS
sufferers of will include.
1. Clinical Management for diagnosis, testing, rational treatment (including
prophylactic interventions) and follow up care.
2. Nursing care to promote and maintain hygiene and nutrition, to asset AU
the
family in day today care and to take necessary precautions.
D.
Introducing and sustaining anti-retroviral therapy
Nothing-should no efforts should be spared to care and treatment HIV/AIDS
victim in our hospitals and health care institutions?
«•
.’’■■■
• |
However, the use of antiretroviral therapy is very expensive and beyond the limits
of sustainability of average India, it should be the Doctor of the individual and the
institution.
E.
<
Treatment
■
As there is no care yet for HIV/AIDS, the only treatment is for opportunistic
infections, which all Catholic Health Care facilities will extend to HIV/AIDS
sufferers of will include.
1.
2.
i
3.
4.
5.
Clinical Management for diagnosis, testing, retinal treatment (including
prophylactic interventions) and follow up care.
Nursing care to promote and maintain hygienic and nutrition, to asset the
family in day-to-day care and to take necessary precautions and to give
health education.
Counselling services
Psychological, pastoral and spiritual support
Social support, including material support when necessary
\\CHAINT\emailin\CD-CME\churchpollcy doc
9
6.
As India is the home of so many alternatives systems of prophylactic
interventions proven and effective remedies which are commonly available
and economically affordable should be encouraged to be used in treating
HIV/AIDS related infection.
The church encourages the development of programmes to care for infants and
children with AIDS, especially those facing life and death without parental care
and encourage heaithy coupies to adopt or sponsor these children.
REHABILITATION
LIVING POSITIVELY
The church urges the people living with HIV/AIDS (PLWHAS) to live positively.
Living positively with HIV/AIDS means^spending time with family and friends.
■
■
■
■
■
■
Planning for the future of loved ones
Maintaining spiritual health
Having hope
Taking care of oneself
Eating a balanced diet
Keeping busy and remaining productivhes
Getting enough physical exercise
Free from substance abuse
Seeking medical help wheneyer an illness arises
Getting enough sleep and r^st
Going for individual and group counseling
Learning about the virus
Protecting others from HIV/Infection
The HIV/Positive person should be guaranteed equal rights to education and
employment as other members of the society. HIV status of a person should be
kept confidential and should not in any way affect the rights of the person to
employment, his or her position at work place, marital relationship and other
fundamental rights.
'
HIV7 positive women should have complete choice in making decisions regarding
pregnancy and childbirth. There should be no forcible abortion or even
L sterilization on the ground of the HIV status of women.
As regards the treatment care and support to PLWAS, the policy should be to
build up continuum of comprehensive care comprising of clinical management,
nursing care, pastoral care, counseling and socio economic support through
home-based care. Resources from the government and community sectors
should be mobilized for this purpose.
To the extent possible, person with HIV/AIDS should be encouraged to continue
to lead productive lives in their community and place of work. They also have the
right to decent housing and landlords are not justified in denying them this right
merely because of their illness.
\\CHAINT\emailin\CD-CME\churchpolicy doc
.■•7 n
v ’r-rrp •rx’ .-■
10
ADVOCACY
I
In spite of the strong IEC campaign on HIV/AIDS there is still inadequate
understanding of the serious implications of the disease among the church
personnel, church leaders, professional agencies, teachers and administrators
not to speak of the medical and paramedical personnel engaged in health care
delivery system. A strong advocacy campaign needs to launched at all level of
the opinion leaders, policy makers and service providers to make them
understand and feel motivated about the need for immediate prevention of the
disease and also for adoption of human and Christian approach towards those
'who are already been infected with HIV/AIDS. The advocacy should start from
the topmost level of hierarchy of the church.
There is a serious information gap about the causes of spread of the disease
even among a large number of medical and paramedical personnel in church run
institutions. This leads to situations of discriminations. HIV/AIDS infected
persons in hospitals and dispensaries and work places not to speak of
community at large. There is a strong need for advocacy, at all levels to
eliminate such discrimination and overreaction both by the authorities, and
general public.
In church related educational institutions HIV/education should be imparted
through curricular and extra curricular approach.
All Christian newspapers and magazines and other print media should be used
for conducting campaigns for social mobilization and generate awareness about
preventions and for sharing information and expertise. The media should be in
general play a positive role in generating an enabling environment for HIV/AIDS
prevention and control and care of the HIV-infected people.
Church related institutional management would initiate intensive advocacy and
sensitization among Doctors, Nurses and other paramedical workers so that
PLWAS are not discriminated, stigmatized or denied or services. The church
expresses serious concern at instances of denial of medical treatment by doctors
in their clinics, nursing homes and hospitals, which is causing enhanced
stigmatization to the PLWAS.
.J
c
.
'
NEED FOR NETWORKING
This global crisis of such great magnitude and^perversity cannot be tackled by
any one single agency, but cooperation and collaboration of all both government
and non-governmental agencies are needed. The church would be ready to
cooperate and collaborate with the National AIDS control organization and State
AIDS control organizations in various States.
Each diocese and congregation are advised to formulate their plans and
strategies to combat HIV/AIDS spread containment and care and management of
HIV/AIDS affected and infected people within their areas of service in dialogue
with all agencies committed to the cause.
WCHAINT\emailin\CD-CME\churchpolicy.doc
11
ECUMENICAL NETWORKING
While we differ widely in certain theological teachings and other Pastoral
practices let us not forget that we are called by the same, Lord, Jesus Christ, to
proclaim His Kingdom and therefore we are united in many common values and
a tradition of Christian service with our brothers and sisters who belong to other
Christian churches. Many of these churches have also been active in responding
to the AIDS pandemic.
Networking with these churches can bring strength to our own catholic efforts in
this field.
CARE FOR THE CARE C
=?S
In the course of our dedicated commitment to the PLWAS, let us not forget the
need to support those who are serving PWAS on a day-to-day basis. Such work
is extremely difficult and can cause physical psychological and spiritual
exhaustion. We encourage^ periodic/ongoing gatherings of HIV/AIDS caregivers
for mutual support and further updating in relevant areas of knowledge and skills,
-3. 2. A_^—P
WCHAINT\emailin\CD-CME\churchpolicy.doc
12
THE CHALLENGE TO BE HIS LIGHT TODAY
A MESSAGE FOR THE WORLD AIDS DAY
December 1,2003
St. Mathew, the evangelist quotes the Prophet Isaiah to introduce the mission and
message of Jesus, in these words; “The people who walked in darkness have seen a great
light, and for those who sat in the region and shadow cf death light has dawned" (Mt.
5:16). As the Chairman of the CBCI Commission for Healthcare, I would like to reflect
with you on this theme intliecontextof the devastating jscourge of HTV/AIDS
' ~ ~ that is
affecting our dear people and the wfiole of our beloved nation.
nat‘
This message is the fruit
of the suggestions by the Bishops in-charge of Health Commissions in the/^Regional
Bishops’ Councils and the Heads of National Health and Developmental Organisations,
who came together for a National Consultation on 'the Response of die Church on
HTV/AIDS’, held on August 8-9, 2003 at St. John’s National Academy of Health
Sciences, Bangalore. As you all know, each year, December 1 is observed globally as
^the World AIDS Day”. Such a reflection is more appropriate since we begin the sacred
season of Advent, and prepare ourselves to celebrate the birth of Jesus, the true Light,
that 'dispels despair and darkness \ and 'enlightens everyone in this world’ (Cf. Jn 1:
5.9).
1.
The first case of Human Immunodeficiency Virus (HIV) was detected in India in
1987. In the last 15 years, the epidemic has spread rapidly all over the country. Today
India has about 4.5 million HIV positive people. The infection is spilling over from highrisk groups, earlier considered as the reservoir of HTV to low-risk groups and from urban
to rural areas. If t^re pandemic continues at its present pace, it is going to have devastating
effects on the entire fabric of our society. It is said that if the spread of HIV/AIDS is not
checked and the problem reversed, it is likely to wipe out decades of development made
in our country. It is also projected that in terms of th^Swnber of the HTV infected, die
Indian subcontinent will overtake the other nations and continents, and will become the
‘AIDS capital of the world’.
j
It is going to pose a formidable challenge to Christian teachings, moral values,
family bonds, marital fidelity, medical care, social work and pastoral care. The situation
is unpredictable - we do not know where it is leading us. The damage done is huge - it
has infected millions. The scourge is unstable - it keeps changing its types and forms,
with no rhyme and^eason for the way it functions. It is invisible - it lies unnoticed within
our body and keeps infecting others. It is dangerous - it affects people mostly in their
productive age, that is, from of 15 to 50 years, which is bound to have irreparable
consequences for any society.
■■
■<
.
•
;
entire Church needs to join hands to make eiforts for HD/ prevention and control. Pooe
John . aui H states that The battle against .AIDS ought to be everyone’s battle.”1 With
existing exigencies ot our country such as poverty. peoMrwTienic conditions illiteracy
ignorance and diversity in culture, tradition andAlanguaXe, it becomes absolutely
necessary tor the Church to get involved in the care and support of the infected and
av/aiene^s building programmes for prevention.
JC^.
In response to div appuabof-the-ffoly Father, the Catholic Church has been a
major provider- of competent and compassionate care
Nations m the fight against this disease2.
provides approximately 25% of the total
major sH^eerter -of
./ if_»u=»
In India, over and above 5000 Catholic healthcare institutions, the Church runs 39 1
care and support centers specifically for those infected with HIV and AIDS in different i
parts 01 the country.
Through the efiorts ot the Commission for Healthcare, the CBCI signed a
Memorandum of Understanding (MoU) with Indm Gandhi National Open University
and a programme of Study on “HIV and FanuiyLfcation^w^laSe^ 'ami ^00
students have enrolled themselves lor this course in the last acidemic year. We know that
education, awareness buddmg and training for the prevention of HIV/AIDS plav a major
role. Hope many more, especially those who are in the education and healthcare field will
join the course and profit by it.
on maintain various piogrammes and projects responding to HTV/AIDS.
In the fight against .AIDS though the Church is involved to a great extent, it still
has a major mission to fulfill. Considering the magnitude of the HIV/AIDS pandemic the
entire Christian community needs to be alive, active and involved. Tollowin«' the
ootsteps of Jesus, the Divine Healer, we need to bung joy and hope to “all those ^ho
to
3 °ne an<1 abandoned m
“reSi°n
of death ’ due
o HIA AIDS. The darkness of their gloom, guilt, ignorance and loneliness need to be
changed into a new hope through gpf love and acceptance.^
11 1 2^S^PaUl affirmS' “1Vo”e °^,ls Iivesfor himself, and no one dies for oneself fRom
14:7-8). If one part suffers, all the parts suffer with it... You are Christ’s body, and
md^dually parts of if fi Cor 12:26-27). One ceases to be a true Christian, when one
ceases to have mercy and compassion m one’s heart towards the suffering and sick, and
■77
discriminates and condemns because the other is infected with HTV. We keep m our
minds these words of the Second Vatican Council saying, “The joy and h<^e, the: gnet
and ansuish of the people of our time, especially of those who are poor and afflicted m
any way, are the joy and hope, the grief and anguish of the followers of Christ as well.
3
Let us change the darkness of ignorance and misconception into the bright world^
of prevention and positive action: HTV infectionHs transmitted mainly m three ways T
through sexual contacts with a person infected and thus-through the exchange-othtoed,
<
semen and va-rinal secreaiions: from a mother infected with HIV tocher baby durmg
nreswwvrdelwerror breast feeding; and through theftransfusions of(blood andhioedproducts. We need to build awareness among t|je people of the nature oi the disease and
,
the ways of its transmission. Prevention means choosing responsible behaviouiaL patterns^
that are based on true hunup and moral values and steieify adhering to them in onejsjife. .
This implies fidehty^Ttoon^s marriage, sexual abstinence outsife-ffifflri^e and
A
responsibility to one’s life and commitment. Tire youth of-tod^--needs"to informed and
formed in the human and reiigious meanings of personal integrity and commitment to
cliastity.
There are many agencies that campaign for prevention of HIV/AIDS by
advocating “safe sex” or “safer sex” through condom use. Unfortunatelydt^pffers a false
sense of security. The^protection it offers- is jmiyth. It has been scientifically established
that condom often fail in prevention of sexually transmitted diseases such as HIV or the
incurable Human Papilloma Virus (HPV) that increases one’s susceptibility to HTV
infection.
Proper awareness on HTV/AIDS should help us to overcome our prejudices and
fears. Those who contract HFV/AIDS, whether by accident or by consequences of their
- j sri own^ actions, carry with them a heavy burden of social stigmatisatien, ostracism and
gjj ^^condemnation. Let us reach out to those infected and welcome them, with a
compassionate heart like that of Jesus! Let us join with the World Health OrganizationJin
the campaign. “Live and let live”, to eliminate stigma and discrimination associated with
HTV and AIDS, J^apgeal to the parish communities, educational institutions and
healthcare facrmres to periodicahv -organize awareness programmes, campaigns and
study-seminars;
4.
Let us help those people living with HIV to come out of the shadow of despair,
gloom and guilt and enter into a joyful hope and acceptance. Those among us who are
living with HIV'AIDS must not feel that they are alone and abandoned. We, who are
their brothers and sisters
must walk in solidarity with them on their
journey. Arour HutyFath&.'pppe John Paul H, has said, “Solidarity is not a feeling of
vague compassion or shallow distress at the misfortunes of so many people. On the
contrary, it is a firm and pfeerying determination to commit oneself to the common
good: tliat is to say, to the good of all and of each individual because we are really
responsible for all.” As the body of Christ, the Church needs to take care of those infected
and help them to ‘live positively’ with HIV/AIDS. I.ct us foliow the footsteps of Jesus
1 the infected.
and
L'k ------ c
7
.j f-j 4i.
1N
A
One of lire senous concerns of the Church is to make sure that the infected
regularly get the antiretroviral (.ARV) treatment at a reasonable price. We are happy that
WHO. together with other agencies is jaunching a campaign this year to provide
antiretroviral medicines to three million(people| by the end of 2005, the “3 to 5” target.
The Church in India whole-heartedly supports this campaign. On behalf of our brothers
and sisters living with HIV. I appeal'^the Pharmaceutical Companies in India, who are
produemg a jarge jhareL_of. the medicine for global supply, that not profit, but
s^ou^ y°ur motive and primary concern.
We need to acknowledge lhe-feet that people living with HIV/AIDS continue to
contribute to their family and society.in their own way. They are to be reassured of the
value ot their lives, their worth in the larger society and the peestbie contribution they can
make to further enrich it.
)
Parish communities, especially through the basic ecclesial communities, should
reach out to those families of HTV patients. We should create 3l network of people
prepared to assist such families in care, counselling and support.
All the Catholic healthcare institutions, as we are serving the Lord in the
abandoned and afflicted, will admit and care for the people living with HTvVaAEDS. As
Blessed Teresa of Calcutta used to say. 'a person affected bv HIV/AIDS is Jesus amon*
How can we say no to him!’ Eveiy'^ed is invited to show compassion and love to
those already mfecte^ We need to know how to fight this disease, while takino care not
to discriminate and stigmatize the infected.
.As we conclude the year of Our Lady of the Rosary, the Mother of Hope and
1 entrust to her maternal care and intercession all those who are living with
HIV/AIDS. May she also intercede for all of us so that the Babe of Bethlehem, may
remove all the shadows of despair, discrimination and fear and bring to our hearts the true
light of hope and loving acceptance of everyone, especially those who are sick and
suffering.
+ Msgr. Bernard Moras
Bishop of Belgaum and
Chairman, CBCI Commission for Health
‘Ecclesia in Africa, Sept. 14, 1995, AAS 88 (1996) 70.
- Umted Nations General Assembly, Special session on HIV/AIDS, June 21,2001, Intervention of Cardinal
Javier Lozano Barragan, President ot the Pontifical Council for Pastoral Health Care, Vatican.
* Vatican II, On the Church m the Modem World, no.l
POLICY AND PLAN OF ACTION
OF THE CHURCH IN INDIA
ON HIV/AIDS
- DRAFT
1. PREAMBLE
The entire Church in India is concerned, at the snowballing increase of
the HIV/AIDS pandemic in this country. The CBCI Commission for
Health Care Apostolate and other National Organizations like Catholic
Health Association of India (CHAI), Catholic Nurses Guild of India
(CNGI), Sister Doctors Forum of India (SDFI) and Medical Institutions
like St. John’s National Academy of Health Sciences, Bangalore, BioMedical Ethics Centre, Mumbai, Fr. Muller’s Charitable Institutions
Mangalore, Pushpagiri Hospital, Tiruvalla, Amala Institute of Medical
Sciences, Trichur, and Developmental organizations like Caritas India,
Catholic Medical Mission Board (CMMB), Catholic Relief Services
(CRS), Indo-German Social Service Society (IGSSS), and Catholic
Religious of India (CRI) and similar Associations came together to form
a common policy and implementation strategy for a collaborative
endeavour to fight against this pandemic.
The personal and social implications of HIV are significant and cannot be
ignored. It seems, indeed, desirable to draw up a policy to address the
implications of HIV/AIDS for Catholic Church institutions and
individuals involved in this field in India, especially with regard to
healthcare services.
As a Catholic body, the Catholic Bishops Conference of India (CBCI)
has developed the policy statement on the foundation of the Gospel and
Catholic: Traditions, in order to present it as a guide to all Catholic
healthcare service, teaching and research institutions in India.
Our Perspectives
The Christian commitment to serve the sick has its mandate from
Christ, the Divine Healer. (Lk 9:1; Mt 10:1; Mk 16:15-18). It is a call
to serve with the same love and compassion of Christ while facing
/
G
human suffering (Cf. Mk 1:41; Mt 20:34), It is a commitment to
continue the action of Jesus, who came to give life and give it in
abundance (Cf Jn 10:10). Our involvement in healthcare is Christ
centered and derives its inspiration and guidance for values and action
from Jesus, the Master.
By the way they are treated and regarded, the people with HIV/AIDS
have become today’s version of the leprosy patients of former times.
In the Gospels, Jesus not only physically cured the ten lepers and the
paralytic, and the women with the hemorrhage, but he also restored to
them their human dignity, and their rightful place in the community.
St. Francis of Assisi and St. Catherine of Sienna kissed the lepers’
sores not simply because they were sores but because they were the
living wounds of Christ’s sufferings. We, too, perceive the same
Christ alive in every individual infected with HIV.
Service to the sick is an integral part of Church’s mission (Cf.
Dolentium Hominum, n.2). Our care, compassion and love towards
those affected by HIV/AIDS are the expression of our faith in
solidarity with them in their pain. Our service to them and to the
members of their family is our genuine response as they are our sisters
and brothers in Jesus the Lord, who is present in those who are
suffering (Cf. Mt 25:45). “Those suffering from HIV/AIDS must be
provided with full care and shown full respect, given every possible
medical, moral and spiritual assistance, and indeed treated in a way
worthy of Christ himself’ (Pope John Paul II).
Our approach is guided by a precise and all-round view of human
person “created in the image of God and endowed with a God-given
dignity and inalienable human rights” (Ecclesia in Asia, 33). We do
not approve any sort of discrimination or hostility directed against
persons with HIV/AIDS, which is unjust and immoral. We uphold the
equality of all people as children of God {Gaudium et Spes).
Our aim is a collective response and an inter-sectorial approach. The
Church is called to collaborate with national and state governments,
international agencies and NGOs, in addressing the issues pertaining
to HIV/AIDS. In our interventions we will adhere to the moral
teachings of the Church.
2
♦
Though we continue to concentrate on care and support of those
infected by HIV, our priority will be the preventive approach with
community participation. So, health education, awareness building,
campaigns for prevention, teaching of values for behavioural change,
etc. will be our strategy.
2. H1V/A1DS in India
Though HIV appeared in India comparatively later than other parts of
the world, it is spreading with unprecedented rapidity. Every region in
India is experiencing a snowballing increase in the transmission of HIV.
The infection is spilling over from high-risk groups, earlier considered as
the reservoir of HIV to low-risk groups and from urban to rural areas. If
the pandemic continues at its present pace, it is going to have devastating
effects on the entire fabric of our society. It is said that if the spread of
HIV/AIDS is not checked and the problem reversed, it is likely to wipe
out decades of development made in our country. It is also projected that
in terms of the number of the HIV infected, the Indian subcontinent will
overtake the other nations and continents, and will become the ‘AIDS
capital of the world’.
It is going to pose a formidable challenge to Christian teachings,
moral values, family bonds, marital fidelity, medical care, social work
and pastoral care. The situation is unpredictable - we do not know where
it is leading us. The damage done is huge - it has infected millions. The
scourge is unstable - it keeps changing its types and forms, with no
rhyme and reason for the way it functions. It is invisible - it lies
unnoticed within our body and keeps infecting others. It is dangerous - it
affects people mostly in their productive age, that is, from of 15 to 50
years, which is bound to have irreparable consequences for any society.
3. TIME TO ACT
>>
The time has come to accept and acknowledge that HIV/AIDS affects
everyone - men and women, young and old, without any distinction of
caste, creed, religion, colour, state, age, sex, profession, qualification,
social and economic status.
3
4
*
It is time for us to pool all our wisdom, knowledge, skills and
resources to fight this pandemic. The time has come to deal with the
disease decisively and to treat the people, who are infected, with
compassion, concern, love and care. We need to learn from the initiatives
taken and the success achieved by those countries that are worst affected
by the pandemic in the recent past.
The entire Church - Bishops, priests, religious and laity - are urged to
join hands to make efforts for HIV prevention and control. All the
Christian teachers and leaders have a unique mission to educate our
people in a way of life that is most likely to protect them from HIV
infection. Every baptized is invited to show compassion and love to those
already infected. We need to know how to fight this disease, while taking
care not to discriminate and stigmatize the infected. As the body of
Christ, the Church needs to take care of those infected and help them to
Tive positively’ with HIV/AIDS. Let us follow the footsteps of Jesus and
walk an extra mile (Mt. 5:41) along with the infected.
We need to acknowledge the fact that people living with HIV/AIDS
continue to contribute to their family and society in their own way. They
are to be reassured of the value of their lives, their worth in the larger
society and the possible contribution they can make to further enrich it.
. 4. THE CHURCH AND ITS NETWORK IN INDIA
The Church in India has always considered healthcare as one of her
major apostolates. This special mission to heal the sick and comfort the
afflicted’ is clear from her presence in the healthcare sector in the country
through about 5000 Hospitals (that includes Health Centers), over 100
Nursing Schools, about 200 Rehabilitation Centers and 5 Medical
Colleges, besides the many other health initiatives, both formal and
informal, including community health programmes. The service rendered
through these institutions in specialized sectors, including HIV/AIDS, is
noteworthy. The Church has a major share of the nation’s healthcare
facility, which is about 15 percent. In other words, the Church in India is
reaching out to approximately 150 million people.
The Church has a very influential position in the educational sphere,
too. She runs around 17,000 educational institutions, which include
Schools: pre-primary to higher secondary; colleges, including community
4
♦
colleges; vocational and technical institutions. It is estimated that these
institutions cater to over 3 million students and, through them, the
Church has an outreach to about 15 million individuals. If we consider
School Health Education as one of the strategies, the influence that the
Church can make in the society is enormous.
Statistics point out that we can make a positive contribution to meet
the challenge caused by the HIV/AIDS pandemic. Once members of the
Church are convinced about her mission and task, the Church could play
a decisive role in the area of prevention and control of HIV/AIDS in the
country.
I)
Concerns of the Church
In trying to be relevant and meaningful for today’s society, through
addressing the issue on HIV/AIDS, the Church has several concerns:
❖ HIV has created panic among people because it is medically so
devastating as there is no vaccine for prevention or drugs for cure. It
threatens life upon which all other values depend.
❖ In India, though HIV was first detected in 1986, the infected are still
being refused treatment, care and support. This deplorable situation is
true in most institutions run by the Government, Church and other
responsible agencies. There is a need for Church-based bodies such
as Dioceses, parishes, basic Christian communities, Religious
Congregations and developmental agencies, etc. to wake up to the
present situation and do all they can to alleviate the suffering and pain
of the infected.
❖ Persons with HIV/AIDS across the country still face large-scale
discrimination and violence that are unjust, immoral and inhuman.
❖ Social realities like poverty, illiteracy, ignorance and oppression, and
psychological factors such as loneliness and isolation, influence
people’s decisions to behave in ways, which expose them to HIV.
❖ There is a gradual deterioration of moral and human values in the
larger society as a result of media explosion and consumerism. This
5
has undermined the sanctity of human sexuality, marriage and
parenting.
♦♦♦ Most of the intervention programmes for prevention and control of
HIV/AIDS are not in line with the religious and socio-cultural
traditions of our nation. This has created misunderstanding and lack
of clarity in addressing the issues related to the pandemic, even
among the Catholic healthcare providers.
2)
Existing Limitations and Hurdles
A close examination of the existing scenario with regard to the prevention
and control of HIV/AIDS, brings to light several limitations and hurdles:
<♦ Public campaigns continue to promote solutions which are contrary
to morality and against human dignity
❖ Lack of awareness and education about the what, why and how of
HIV/AIDS among most of the people
♦♦♦ Large scale abuse of drugs and sexual promiscuity
<♦ Lack of concerted effort in providing HIV/AIDS education in
School and University curriculum and in catechism/moral
education programmes
♦♦♦ Most infected in rural as well as in urban areas are unaware of tlieir
state of infection
Government and non-governmental funding for HIV/AIDS
research, treatment, care and rehabilitation continue to remain
inadequate
❖ The existing healthcare system does not have required facilities
such as infrastructure, medical equipment and trained personnel to
take care of the infected
♦♦♦ Dearth of professionally trained personnel/institutions where
healthcare providers and educators can get adequate framing and
guidance in line with the teachings of the Church
Inadequate intervention from the media and insufficient
involvement of leaders of the Church communities at various
levels
3) Goals And Objectives of the Church’s Involvement
❖ To follow the mandate given by the Lord “to heal every disease and
every infirmity” (Mt 10:1) and give care (Cf Mk 16:18)
6
♦
♦♦♦ To evolve a set of meaningful strategies and plan of action for timely
intervention in the prevention and control of HIV/AIDS
❖ To provide a set of guidelines to healthcare workers in Catholic
institutions for offering compassionate and loving care to the infected
in various settings such as hospitals, hospices, palliative care units,
community and families.
♦♦♦ To motivate schoolteachers and other academicians in Catholic
Institutions to make appropriate health education interventions.
♦♦♦ To conscienticize people on HIV/AIDS preventions and control and.
with Christ-like charity and concern, to take care for those infected.
<♦ To help people to perceive the HIV/AIDS pandemic and those
infected with a right and non-judgmental attitude.
4)
Strategies To Be Adopted
I. Prevention
II. Treatment
III. Care and Support for Living Positively
IV. Networking
V. Research
VI. Advocacy
I.
Prevention
Concept HIV/AIDS is an epidemic that can be prevented, since it is
spread through certain definite and limited routes. The HIV virus
spreads through sexual activities, transfusion of unscreened blood and
blood products, contaminated needles/syringes and from an infected
mother to her child during pregnancy, childbirth or through
breastfeeding. Once the HIV infection is established, it is for life and
will probably succumb to serious opportunistic infections caused by
the weakening of the person’s immune system.
i.
Information, Education and Communication (IEC)
With the help of Information, Education and Communication people
can be motivated to adopt and maintain healthy practices and
lifestyles. This will protect them from acquiring infections and ill
7
*
*
-z-—- •
health. IEC is useful in educating the public by clarifying general
misconceptions and ignorance.
A) The objectives of IEC strategy are:
a) To raise awareness, improve knowledge and understanding
among the general population about HIV/AIDS infection
and STDs, routes of transmission and methods of prevention
b) To promote desirable practices such as:
- avoiding sex outside marriage
sterilization of needles/syringes; use of
disposable needles/syringes
- encouraging voluntary donation of blood
c) To mobilize all sectors of the Church to integrate messages
and programmes on HIV/AIDS into their existing activities
d) To train healthcare providers, schoolteachers, NGO
functionaries and other volunteers in HIV/AIDS counseling,
communication and coping strategies
e) To create a supportive environment for the care and positive
living of people with HIV/AIDS
The IEC strategic plan has the following components:
A. Multimedia Awareness Campaign: Awareness building can be done
through well-designed materials. Posters, pamphlets, booklets, newspaper
advertisements, film clippings, TV spots, radio spots, wall paintings and
cinema slides, street plays etc.
B) Education programmes:
a) The CBCI-IGNOU Chair for Health and Social Welfare has
launched a Diploma and Certificate programme of Study on
“HIV and Family Education” through correspondence
courses. People from any part of the country can benefit
from this programme.
b) CHAI’s AIDS Desk has training programmes.
c) CNGI’s Hope Centre has special programmes for nurses in
pre-test and post-test counseling
d) St. John’s National Academy of Health Sciences, Bangalore
organizes training programmes for healthcare providers,
pastors, etc.
8
*
C). An inter-sectorial networking effort:
a). CBCI Commission for Health will collaborate with other
Commissions such as Education, Youth, Women, Labour,
Communication, etc.
b). Motivate Communication and Media Centers for preparation
of IEC materials which are locally relevant The print and
electronic media need to give adequate coverage on this
pandemic and the efforts made for its prevention and control by
the Church-related institutions
c). Education and Healthcare Institutions need to concentrate on
IEC implementation
d). Youth Organizations such as ICYM, YCS/YSM, AICUF,
YCWS and similar other youth groups are to be motivated
11.
Universal Precautions (Hospitals & Primary Health Centers)
. .pi: Universal precautions consist of a set of guidelines created to
prevent the spread of diseases transmitted through body fluids, blood
spillage, soiled linen, etc. for the protection of caregivers. These precautions
were created primarily for medical professionals working in a hospital
setting whenever they are likely to come into contact with blood or other
body fluids. Because any patient could be infected, all blood must be treated
as infected by any person handling or exposed to blood. These precautions
also apply to other bodily fluids that are a potential source of HIV. including
semen, vaginal secretions and tissues.
Universal precautions include the following practices:
A) Washing the hands with soap and water before and after
contact with each patient. Hands should always be washed
even when gloves are worn. If one touches blood or other
bodily fluids by mistake, hands are to be washed thoroughly.
Therefore, adequate facilities such as wash basin, liquid
soap (preferably with antiseptics like chlorhexidine) and
disposable paper towels should be made available in all
areas and wards of the hospital and centers of care.
9
B) Disposable plastic gloves should be worn by anyone
collecting or handling blood or bodily fluids. Double gloves
are to be used during surgical procedures. Those with open
skin lesions should not perform procedures if they are
exposed to body fluids. Used gloves should be disinfected
with bleach and disposed off.
C) Wearing of gowns when clothes may be exposed to body
fluids.
D) Wearing of masks and eyewear when performing procedures
that may splash the worker with body fluids.
E) Disposal of ward wastes:
a) Infected wastes: Any waste that comes in contact with
blood or body fluids should be considered infected. Such
waste should be collected in bins lined with plastic garbage
bags. Once filled the bag should be tied up and marked with
a biohazard label. They should be transported in a closed
trolley to prevent spillage. The bag should be incinerated
unopened.
b) Sharp wastes: Sharp instruments should be disposed
of in puncture-resistant containers immediately after use.
Needles should be disposed of immediately after use without
recapping. Disposal containers should be placed in all areas
where sharp objects are used.
111.
Awareness Campaign
A) Schools/Colleges
a) Catholic Colleges, Colleges/Schools of
Social Work; Associations like AINACS, Xavier
Board of Education etc. are to be involved
b) Moral education classes/catechism classes
can be a forum where information-sharing on HIV
and related areas such as character formation, life
style behaviours, etc., can be dealt with
c) Schools/Colleges could organize talks by
experts on HIV/AIDS in line with Church
magisterium; seminars, debates, poster-making or
painting competitions, etc.
10
*
d) Youth forums like NSS, AICUF etc, could
integrate HIV/AIDS prevention programmes into
their activities.
e) Catholic medical colleges and nursing
schools need to incorporate HIV/AIDS topics into
their curriculum which is in line with the
magisterium of the Church
f) Colleges could organize voluntary donation
programmes once in a year
B)
a) A pastoral letter by the diocesan bishop on
the issue of HIV/AIDS which is to be read
in the communities on the Sunday nearer to
the World AIDS Day (December 1)
b) Formation of a group of experts / trainers of
trainees (TOTs) who will be available for
awareness building
c) Topics on HIV/AIDS can be incorporated in
the marriage preparation courses
of
d) Encouraging
the
opening
hospices/palliative care centers in the
Diocese if need be
C)
Parishes and basic Christian couimcaities
a) The parish community can be enlightened
about the what, why and how of HIV as well
as the need to adopt a compassionate and
caring approach to the people living with
HIV/AIDS
b) Organizing a HIV/AIDS Sunday every year,
preferably on the last Sunday of November
or first Sunday of December (as World
AIDS Day falls on December 1 every year)
c) As a sign of solidarity to the infected,
mobilization of funds for their care and
support and for IEC (preferably a Sunday
collection)
11
t
d) At the parish and BCC level, initiatives need
to be taken to create a conducive atmosphere
for those living with HIV
e) Organizing voluntary blood donation camps
D)
a) HIV/AIDS related topics should become a
part of the curriculum in the seminaries and
formation houses of the religious
b) Possibility of providing exposure /
involvement in HIV related care and support
initiatives for the candidates in formation
houses
c) Encourage blood donation at least once in a
year
E)
Viliaue commumnt--- and
a) Sensitization programmes need to be
organized at the village level by Churchrelated NGOs, so that the entire community
is prepared to accept the reality and extend
care and support
b) To bring about behavioural changes on life
style that may otherwise cause HIV
infection, such as promiscuity, drug abuse
etc.
5.
ROUTES OF HIV TRANSMISSION
There are three well-known routes of transmission of HIV from one
person to another, namely, sex, blood and from mother to child. Unlike other
killer diseases like cancer and heart attack, HIV/AIDS is one in which we
exactly know how it is spreading from one person to another. We also know
the ways and means of prevention. Therefore, if there is a will to prevent and
control the transmission of HIV, one can certainly dream of a world free of
HIV/AIDS.
12
«
1) HI V I r wmission through sex
: The Catholic Church promotes some of the best educational
programmes designed to prevent the transmission of HIV through sexual
activities. Several dioceses in India have introduced Marriage Preparation
Courses as a pre-requisite to the reception of the Sacrament of Matrimony.
Many of these programmes do have components relating to the purpose and
value of sex and sexuality, HIV/AIDS, family life education, etc. The Health
Commission of CBCI has also developed a set of excellent print materials.
Apart from this, the Commission also facilitated the preparation and
launching of two programmes of study on 4HIV and Family Education'
through distance learning correspondence courses at Indira Gandhi National
Open University, Delhi. Organizations like CHAI and several dioceses have
developed curriculum/materials in line with the teachings of the Church for
the benefit of the people. These programmes aim at helping young people to
learn about their bodies, to develop mature interpersonal relationships and
the need to attain self-discipline so that they will not be exploited or become
manipulative. The core message of these initiatives is that sexual activity is
to be restricted to faithful marriages and abstinence can and must be
practiced outside marriage.
❖ The Church should continue to uphold and promote the values embodied
in her teaching of sexual abstinence before marriage and fidelity within
marriage
❖ The Church should provide accurate and complete information on all
means of HIV prevention so that the people are enabled to take appropriate
decisions in consultation with their spiritual guides
❖ Through the educational and healthcare institutions, the Church should
make efforts to provide adolescent sexual health education in line with the
Magisterium of the Church
i
of Condom
•>
Since the most common means of HIV spread is through sexual activities,
most governments, donor agencies and NGOs continue to advocate the use
of the latex condom as a popular means for prevention of HIV/AIDS. One
needs to speak the truth about condoms that it is not 100 percent safe. In fact
advocates of condom use promote premarital sex, extra-marital sex and
infidelity, which are not acceptable to the Church’s teachings.
13
However, in exceptional cases where one of the partners is infected the
couple may seek appropriate guidance from their spiritual father/guide.
2) Blood
: The second most common route of HIV transmission in India is
through blood and blood products. There are several diseases that are
transmissible via blood, such as HIV/AIDS, syphilis, malaria and other viral
infections. Therefore, transmission of blood can lead to transmission of
blood transmissible diseases. In fact studies have shown that transfusion of
HIV infected blood is the most common means of transmitting HIV/AIDS
infection. The transmission rate of HIV via blood is estimated to be 90
percent.
Our healthcare system is managed by thousands of physicians, nurses and
other para-medicals who come in close contact with the blood of patients
whom they serve. Several cases have been reported from across the country
about healthcare providers getting infected through needle prick and surgical
instruments.
It is a fact that the HIV infection rate in some states is due to drug addicts’
practice of injecting drugs into their veins and sharing needles. The Church
has several de-addiction centers that provide care, treatment, counseling and
spiritual guidance to the victims.
Thalassemic patients are at a higher risk of getting infected with HIV
through blood transfusion. Similarly people with bum injuries too face the
vulnerability of the use of first aid, namely, the use of fresh placenta.
Similarly other sources of HIV infection involve barbershops, skin-piercing
instniments including tattooing, etc.
<♦ Every unit of blood should be tested for HIV before transmission of
blood
♦♦♦ Before organ transplantation or use of blood products the HIV status of
the donor should be established
♦♦♦ Use of sterile needles/disposable needles and syringes should made
mandatory in every hospital & health clinics
❖ For healthy and hygienic reasons ear and nose piercing need to be done
by a qualified person using sterile instruments
14
i
❖ Avoid injecting drugs and needle sharing
♦♦♦ Healthcare providers must follow the universal precautions promoted by
WHO
3)
Mother to Child Transmission
: Child victims are die horrifying new faces of HIV/AIDS in India.
One of the three main known routes of transmission of HIV from one person
to another is the transmission from a mother to her child during pregnancy,
during child-birth and through breast feeding. Although every child bom to
an HIV positive mother will test positive to antibodies for HIV, only about
25 to 30 percent are likely to get infected with HIV/AIDS. Through
advanced medication the chances of a child getting infected during
pregnancy has been reduced.
-
6.
HIV positive mothers should avoid pregnancy
In case a woman is pregnant, and HIV positive, she should continue
her pregnancy, and do not opt for abortion, because about 75 percent
of
children
----------n are known to be surviving the risk of getting infected with
HIV/AIDS
HIV positive mothers should opt for caesarean because through
normal delivery a child has every chance to get infected during the
process of a normal delivery
HIV positive mothers may avoid breast-feeding
TESTING:
In HIV/AIDS testing all church institutions shall follow the guidelines
prescribed below:
1) No individual should be made to undergo a mandatory testing
for HIV.
2) No mandatory HIV testing should be imposed as a precondition
for employment or for providing health care facilities during
employment.
3) In case a person likes to get his HIV status certified through
testing all necessary facilities should be given to that person
and results should be kept strictly confidential and should be
given out to the person and with his consent, to the members of
15
*
his family/relatives and friends. Disclosure of HIV status to the
spouse of the person is recommended as a sign of responsibility
and mutual love to the partner. This will also help the person in
getting proper home care when he/she is living with HIV/AIDS.
4) In case of marriage, if one of the partners insists on a test to
verify the HIV status of the other partner, the contracting party
to the satisfaction of the person concerned should carry out
such tests.
5) Every testing center should have the facility for pre-test
counselling and post-test counselling in HIV/AIDS by
professionally qualified counsellors or they should be referred
to such professionals.
6) If a first test proves HIV positive, do a re-test to procure
certainty about test results.
7.
Treatment
As there is no cure yet for HIV/AIDS, the only treatment is for opportunistic
infections, which all Catholic Healthcare facilities will extend to people
living with HIV/AIDS. This will include:
❖ Clinical Management for diagnosis, testing, retinal treatment
(including prophylactic interventions) and follow-up care
<♦ Nursing care to promote and maintain hygiene and nutrition; to
assist the family in day-to-day care of the patients and to take
necessary precautions suggested under universal precautions above
<♦ Counselling services
❖ Psychological, pastoral and spiritual support
Socio-economic support, wherever necessary and possible
❖ As India is the home of so many alternative systems of medicines
(proven and effective remedies) in treating HIV/AIDS related
infections, we should encourage use of those that are commonly
available and economically affordable should be encouraged to be
used.
*
16
8.
1.
CARE AND SUPPORT FOR LIVING POSITIVELY
LIVING POSITIVELY
The Church urges the people living with HIV/AIDS (PLWHAS) to live
positively. Living positively with HIV/AIDS means spending time with
family and friends while contributing whatever they can for the benefit of
the family and the society.
<♦ Continuing one’s profession as long as one is able to do so
❖ Planning for the future of loved ones
❖ Maintaining spiritual health
Having hope
Taking care of oneself
Eating a balanced diet
<♦ Keeping busy and remaining productive
❖ Getting enough physical exercise
♦♦♦ Free from substance abuse
<♦ Seeking medical help whenever an illness arises
<♦ Getting enough sleep and rest
♦> Going for individual and group counseling
❖ Learning about the virus
♦♦♦ Protecting others from HIV infection
The HIV-Positive person should be guaranteed equal rights to education and
employment as other members of the society. HIV status of a person should
be kept confidential and should not in any way affect the rights of the person
to employment, his or her position at the work place, marital relationship
and other fundamental rights.
As regards the treatment care and support to people living with HIV/AIDS,
the policy is to build up a continuum of comprehensive care comprising of
clinical management, nursing care, pastoral care, counseling and socio
economic support tluough home-based care. Resources from the government
and community sectors should be mobilized for this purpose.
1) Institutional Care
❖ Christian Institutions should be visible manifestations of God’s Love.
17
❖ All members of healthcare institutions recognise then obligations to
render all possible and adequate care to every patient. There will be no
discrimination on the basis of HIV status in matters of admissions and
treatment
❖ Our hospitals are encouraged to establish diagnostic facilities, which will
include those for testing for HIV and STD.
❖ Our health care institutions will provide healthcare services social and
counselling support and spiritual and pastoral care to the people with
HIV/AIDS. Every hospital will have at least one trained counsellor.
❖ All Catholic healthcare institutions will take adequate infection control
measures (universal precautions) to the greatest possible extent.
❖ Each institution will have a designated person as contact/liaison person
for all matters connected with HIV/AIDS. Larger institutions and
dioceses will have HIV/AIDS committees.
3) Home Based Care
This is an integral part of caring. It is needed when the individual has
developed AIDS or even during a bout of opportunistic infection, family
members or anyone available provides home-based care. Home-based care
includes treatment of common symptoms such as fever, diarrhoea, cough
and other health problems related to HIV/AIDS. It is basically palliative in
namre and includes maintaining proper nutrition and patient hygiene.
Families and caregivers at home need to be tramed in day-to-day care of the
patient. The training should include aspects such as planning a balanced
diet, principles of hygiene, disposal of soiled linen, etc.
4) Community- based care
As there is no cure yet for HIV/Al DS, the only possible treatment is for
opportunistic infection, which all Catholic healthcare facilities will
extend to HIV/AIDS sufferers. This includes:
❖ ClinicarManagement for diagnosis, testing, rational treatment (including
prophylactic interventions) and follow-up care.
❖ Nursing care to promote and maintain hygiene and nutrition, to assist the
family in day-to-day care and to take necessary precautions.
18
9.
ADVOCACY
In spite of the strong IEC campaign on HIV/AIDS there is still inadequate
understanding of the serious implications of the disease among the Church
personnel, Church leaders, professional agencies, teachers and
administrators, not to speak of the medical and paramedical personnel
engaged in the healthcare delivery system. A strong advocacy campaign
needs to launched at all levels of the opinion and policy makers and service
providers so as to make them understand and feel motivated about the need
for immediate prevention of the disease and also for adoption of human and
Christian approach towards those who have already been infected with
HIV/AIDS.
There is a serious infonnation gap about the causes of spread of the disease
even among a large number of medical and paramedical personnel in
Church-run institutions. This leads to situations of discrimination against
HIV/AIDS-infected persons in hospitals, and dispensaries and work places,
not to speak of the community at large. There is a strong need for advocacy,
at all levels to eliminate such discrimination and over-reaction both by those
who are holding offices and the general public.
In Church-related educational institutions, HIV/education
imparted through both curricular and extra-curricular activities.
should be
All Christian newspapers, and magazines and other print media should be
used for conducting campaigns for social mobilization and awareness raising
over prevention, and for sharing information and expertise. In general, the
media should play a positive role in creating an enabling environment for
HIV/AIDS prevention and control, and for the care of the HIV-infected
people.
Church-related institutional management would initiate intensive advocacy
and sensitization among doctors, nurses and other paramedical workers so
that peoplejiving with HIV/AIDS are not discriminated against, stigmatized
or denied necessaiy services. The Church expresses serious concern over
instances of denial of medical treatment by doctors in their clinics, nursing
homes and hospitals, which is causing enhanced stigmatization of the people
living with HIV/AIDS.
/9
♦
1). Need For Networking
This global crisis of such great magnitude and perversity cannot be tackled
by any one single agency, but through cooperation and collaboration of all:
both government and non-governmental agencies are needed. The Church
would be ready to cooperate and collaborate with the National AIDS Control
Organization (NACO), State AIDS Society in various States, UN Agencies
and other NGOs .
Each diocese and congregation is advised to formulate their plans and
strategies within its areas of service in dialogue with all agencies committed
to the cause: to combat HIV/AIDS spread, to attempt its containment, and to
provide care and management for HIV/AIDS affected and infected people.
A. Ecumenical Networking
While we may differ in certain theological teachings and other Pastoral
practices from our brothers and sisters who belong to other Christian
churches, let us not forget that we are called by the same Lord, Jesus Christ
to proclaim His Kingdom. Therefore, we are united in many common values
and the tradition of Christian service. Many of these churches have also been
active in responding to the AIDS pandemic. Networking with these churches
can bring strength to our own Catholic efforts in this field.
B. Care and treatment of the patients
There is no cure; but there is no limit to care.
❖ Medical Care
<♦ Nursing Care
<♦ Emotional Support
❖ Financial Support
♦♦♦ Spiritual Support in grief and dying
❖ Support to the Family Members and Relatives
C. Pastoral Care
D. Rehabilitation
Possibilities of jobs or income generation programmes for those who
are living with HIV
20
♦
For children who are orphaned, possibilities for their education and
settlement.
E. Living Positively with HIV
2) Issues Involved
Medical
> Ethical
> Social
> Religious
'r Humanitarian
> Discrimination
> Misconceptions
> Education & Training
'r Documentation and Material Production
I.
II.
III.
Care of the caregix ers
Care
Agents of Implementation
Church Leaders (Bishops, CRI, Religious, priests &
laity)
11.
Hospitals and Para-medicals; Associations
iii. Educational institutions; Welfare Units
iv. NGOs
1.
3) Process of Implementation
r Circulation of the policy
r Pastoral Letters by Bishops
> Awareness building programmes:
AIDS Day (Dec. 1)
Day for Orphans due to HIV (Dec. 28- Feast of Holy Infants)
< AIDS Desk
r Training Programmes (e.g. Certificate Course on “HIV & Family
Education” by CBCI-IGNOU Chair on Health and Social Welfare)
r CHAI, St. John’s, etc. working together
r Resource mobilization
21
> Expert Group at Diocesan, Regional & State level
'r Inclusion in the Seminary curriculum, Nursing/Medical Syllabi
> Home-based care programmes and personnel
•>
22
i
n-»^>»-T'';x^'-5r'r^,"c'»»’rrr,7«^?>riTT*VT>',ncF’rFTwrr
yis-7-M •
The Church’s Collective Response to HIV/AIDS
and
Scale-up Action in India
Report on Special Consultation of Bishops
And
Representatives of Major Health and Development Organizations
8-9 August 2003
St. John’s Academy of Health Sciences
Bangalore, India
During a consultation supported by the Catholic Medical Mission Board (CMMB), of New York, I SA.
and held in Bangalore on 8-9 August 2003, members of the hierarchy and leaders of Catholicsponsored health and social development services in India committed to a strategic and collaborative
response to the rapidly worsening situation ofHlV/AIDS in the country. Participation in this event
included eleven bishops (presidents of the Regional Health Commissions associated with the Indian
Episcopal Conference), officers and staff of the Health Commission at the Catholic Bishops’
Conference of India (CBC1), the Catholic Health Association of India, Caritas India, the Sister doctors
Forum of India, the Catholic Nurses guild of India (CNGI), as well as experts from Indira Ghandi
Open University of India (Delhi), the Community Health Cell (Bangalore), Amala Cancer Research
Centre (Kerala), and Amala Ayurveda Hospital (Kerala). Guests coming from outside the country
included: Dr. Rabia Mathai, Global Director of Programs at CMMB; Rev. Robert .1. Vitillo, CoChairperson of the Caritas International is HIV/AIDS Task Force; Rev. Michael Perry, OEM, Policy
Advisor for Africa, United States Conference of Catholic Bishops; Mr. Marc D'Silva, Catholic Relief
Services; and Dr. Mario De Souza, Advisor to the Health Ministry in Oman.
*
In opening the session. Rev. Alex Vadakumthala, Executive Secretary of the CBCI Commission for
Health, spoke of the continuing stigmatization and marginalization directed toward those living with or
otherwise affected by HIV in India. He mentioned specifically the newspaper reports, in July 2003,
about a woman in Andhra Pradesh woman who died in abominable circumstances and may even ha\ c
been stoned to death when she returned to her home village after receiving a diagnosis of HIV
infection. Subsequent to her death, her own family refused to re-claim her ashes at the crematorium. 11c
also cited the case of two brothers in Kerala, whose parents died of AIDS-related illnesses, and who
were ejected from school after the parents of their classmates refused to send their own children lo the
school unless these two orphans were expelled. Finally, some Catholic religious sisters adopted the
boys and are providing for their education. Fr. Alex said that such ignorance and fear added to the
motivation for this consultation, the major goal of which was to promote additional, collective action in
response to HIV/AIDS in India.
In offering the first words of welcome. Bishop Ignatius Menezes, of the Diocese of Ajmer-Jaipur, said
that no longer could one claim that HIV/AIDS is a problem of the West, since it has taken root in the
East as well and that the Church must respond to this situation. In his words of welcome. Archbishop
Concessao, of Delhi, who also serves as CBCI Vice President, said that Jesus embodied the compassion
of the poor and suffering, and in particular of the least ones in society. In fact, these persons provided
an opportunity to be served and thus, through them, Jesus could show what God was like a
compassionate savior who is accepting of all. The archbishop cited Jesus’ approach to the lepers; any
A * *5
•
(fto kt |V I
1
physical contact with them was unthinkable in Jesus’ time, yet he touched them and, against the
prevailing law, he recognized them, made them feel at home, and healed them. In this manner. Jesus
produced a “counter culture”. The Church serves as a sign and sacrament of Jesus’ continuing presence
in the world today. The presence of HIV/AIDS among us gives the Church an opportunity to exercise
Jesus’ ministry to and acceptance of people so affected as well as to reiterate its moral teaching based
upon natural law. The archbishop pointed out that India has the dubious distinction of being the “AIDS
capital” of the twenty-first century and insisted that the Church must help to prevent the spread of the
virus and to care for those already affected.
The Global Epidemiology of HIV/AIDS - Current and Future Trends
Rev. Robert J. Vitillo pointed out the fact that the pandemic of AIDS is comparable in magnitude to the
worst and most tragic pandemics in history; these have tended to infect between 20%-50% of certain
elements in the population. He then citied some striking dimensions of this pandemic;
Approximately 42 million people living with HIV/AIDS by the end of 2002
5 million new infections in 2002
3.1 million deaths due to AIDS in 2002
Approximately 14,000 new HIV infections in 2002
o More than 95% are in developing countries
o 2000 in children under 15 years of age
o of the remaining 12,000
■ almost 50% are among women
■ approximately 50% are among 15-24 year-olds
Fr. Vitillo identified sub-Saharan Africa as the most affected region at the present time with 29.4
million people living with HIV/AIDS at the end of 2002. In four southern African countries, adult sero
prevalence rate exceeds 30%. Food crises in three of these countries (Lesotho, Swaziland, and
Zimbabwe) are linked to the toll of HIV. AIDS causes twice as many deaths in the region than those
caused by the second leading “killer disease” (lower respiratory infections) and almost 2.5 limes the
number of deaths caused by malaria.
rhe following historical perspective on the spread of HIV in Asia and Pacific was offered:
•
•
•
•
During the early to mid-1980s, there was extensive spread among men who engage in same-sex
contact, especially in Australia, Japan, Malaysia, New Zealand, Singapore and Hong Kong
During the mid- to late 1980s, high HIV prevalence was documented among other populations w ilh
high risk behavior (50% or more among female sex workers in Thailand and in parts of India, notably
Mumbai)
In addition, at the same time, there was HIV spread among Injecting Drug Users (IDUs) in Thailand,
Northeast India, and the “Golden Triangle” area of China, Myanmar, and Thailand
During the 1990s, in several South and South-east Asian countries (Cambodia, parts of India.
Myanmar and Thailand), significant heterosexual transmission continued or was first noticed.
1 /7/1 I/DS in Asia and the Pacific Region, World Health Organization, 2001
2
•
An explosive spread of HIV occurred within IDU populations (levels of more than 50% within 1 -2
years in several provinces of China, north-east India, Malaysia, Myanmar, Pakistan, Thailand, and
Vietnam, Indonesia, and Nepal.
Some key features about the current situation of HIV/AIDS in the region- were mentioned as follows:
• Almost 1 million people in this region acquired HIV during 2002 a 10% increase since 2001
bringing the estimated number of people living with HIV there to 7.2 million.
• China and India are experiencing serious, localized epidemics that are affecting millions of people.
• Although India’s national adult HIV prevalence rate remains at less than 1%, it has an estimated
3.97 million living with HIV the largest number in a single country with the exception of South
Africa.
• The epidemic in China shows no signs of abating.
• Official estimates put the number of HIV-infected people there at 1 million; there was a 17%
increase in new infections in the first six months of 2002.
• The country is marked by widening socioeconomic disparities and extensive migration (more than
100 million Chinese living outside their home regions) these factors have strong influences on the
spread of the epidemic.
Fr. Vitillo pointed out the potential for an increasing HIV burden in Asia by comparing the respective
general population numbers and the distribution of adult HIV infection in Asia :
Asia and Pacific
Sub-Saharan Africa
% of World’s Population
Distribution of Adult HIV
Infection
60%
8%
18%
70%
He then sounded an alert conceming factors that could contribute to an increase in HIV within South
Asia4:
54% of its population is under the age of 25 - the age of vulnerability for risk taking behavior
There is ample evidence of sexual activity and of injecting drug use among young people
in Maharashtra, a study of adolescent, married people indicated that 48% of boys had engaged
in premarital sex
in Nepal, HIV prevalence among IDUs increased from 2.2% in 1995 to nearly 50% in 1998
Thousands of children live and work on the streets many abused, marginalised, unaware of
HIV risk
Alter reviewing HIV/AIDS trends in the other regions of the world, Fr. Vitillo expressed grave concern
about the projected “Second Wave” of the pandemic at the beginning of the twenty-first century:
Five countries Nigeria, Ethiopia, Russia, India, and China
million people living with HIV.
UNAIDS Report. December 2002.
HU' .1 IDS in Asia and the Pacific Region, World Health Organization, 2001
4 South Asia: The HIV/AIDS Epidemic. VSilCEY, 2001.
will be burdened with some 50 to 75
In Nigeria, life expectancy is expected to decrease to age 47. compared with 61 before the
arrival of AIDS; and in Ethiopia, to 40, from 53 before the onset of disease.
In addition to the increased health care costs, the burgeoning number of orphans due to the
death to AIDS of one or both parents, other catastrophes forecast for these countries by 2010
include:
o famines,
o civil wars
o economic reversals
o collapse of social and political institutions
The presenter then detailed some of the impact of HIV/AIDS on social development and on the
integrity of both families and individuals:
Impact on Population and Life Expectancy
U.N. Population Division estimates that the population of the 45 most affected countries will be
97 million smaller in 2015 and that the world population will be 480 million smaller by 2050
India alone will account for 47 million additional AIDS-related deaths and China will account
for an additional 40 million such deaths.
Life expectancy in Sub-Saharan Africa is the same as it was in tenth century Europe
Impact on the Family
A study in Cote d’Ivoire indicated that health-care costs rose by up to 400% when a family
member had AIDS
Households in both Thailand and Tanzania reported spending up to 50% more on funerals than
on medical care
Research in Tanzania showed that individuals’ food consumption dropped by 15% in the
poorest households after the death of an adult to HIV/AIDS
Staggering Increases in the number of Orphans bring the risk of a “lost generation
with little or no education
poor socialization
social upheaval
economic underclass
Education systems are collapsing'
AIDS has an impact on both the availability and the use of schooling
In Central African Republic and Swaziland, school enrollment is reported to have fallen by 20"<>
and 36% due to AIDS and orphan hood, with girl children most affected
In Guatemala, studies have shown that more than a third of children orphaned by HIV AIDS
drop out of school
’ Source: UNAIDS Barcelona Report, 2002.
'■ H!\ -I/OS' Implications for Poverty Reduction. United Nations Development Program Background Paper prepared for the I \
General Assembly Special Session on HIV/AIDS, 25-27 June 2001.
4
Reactions to HIV/AIDS often cause stigmatization and marginalization
o Studies in Cote D’Ivoire and South Africa show that, in places with extremely high HIV
prevalence, women refused testing or did not return for their results
o In southern Africa, a study on needle stick injuries found that nurses did not report the injuries
because they did not want to be tested for HIV
o In a study on home-care, fewer that 1 in 10 people caring for an HIV patient acknowledged the
disease affecting their loved one
Privacy and Confidentiality are often compromised
Many people, including some clergy, have the false concept that HIV could be spread by casual
means and think that HIV-infected need to be publicly identified in order to avoid infection
Instead of adopting “universal” health care precautions - valid preventing spread of HIV and
other blood-borne diseases, some health care workers think that HIV patients require special
precautionary measures and thus disregard the patient’s right to confidentiality
omen are severely affected
Women are more vulnerable to HIV/AIDS because they have less secure employment, lower
incomes, less access to formal social security, less entitlement to assets and savings, and little
power to negotiate sexual contacts
They are more likely to be poorly educated and have uncertain access to land, credit, and
education
Women-headed households are poorer and have less control over productive resources
Some simple math can save the developing world
Macroeconomist, Jeffrey Sachs, says that we could fight malaria, TB. and HIV. by pro\ iding
medications, technology, and prevention funding to the poorest countries with only $27 billion
per year; that is 1/1000 of the income of the “rich countries
Sachs maintains that we could save 8 million lives per year if the “rich world’1 were willing to
set aside 10 cents on every $1000
o
Ma jor Learnings at the Present Stage of the Pandemic*
The HIV/AIDS pandemic is still at an early development and its long-term evolution is still
unclear.
Some success in prevention activities (e.g., in Thailand and Uganda) has been achieved in
particular countries - usually this has happened with a multi-sectoral approach and with active
involvement of young people.
A necessary component in this success has been community mobilization, including elimination
of stigma, partnership between government and others in the community, and involvement of
all sectors in the community.
Access to comprehensive care and treatment for HIV/AIDS is not an optional luxury in global
responses - this must be made available in all parts of the world.
AIDS 2002 Today. Newsletter of XIV International Conference on AIDS. 10 July 2002 and Jeffrey Sachs Senior Lecture al
Barcelona. 1 1 July 2002.
s UNAIDS Barcelona 2002 Report
5
It is crucial to address the economic, political, and cultural factors that render individuals and
communities vulnerable to HIV/AIDS.
While the lack of capacity and infrastructure must be addressed in developing countries, it
should not be an obstacle to making comprehensive care and prevention available in ail
countries that show a commitment to an expanded response.
HIV/AIDS in India - Church’s Responsibility
Dr. G.D. Ravindran, of St. John’s Medical College Hospital, Bangalore, presented on this topic. The
first case of HIV was detected in India in 1987. In the last 15 years, the epidemic has spread rapidly
throughout the country. Today India has approximately 4 million people infected with HI V.
HIV increases the mortality and morbidity rates of the affected communities. It will increase the infant
and under-five mortality. The number of orphans will increase; it also produces emotional trauma and
discrimination among the infected individuals.
HIV/AIDS also has an economic impact. The work force of the country will be affected as will be
young adults. National budget of health care is likely to increase as the demand for care increases.
Poverty worsens inequality and increases human rights abuses.
89% of infections occur among the sexually active and economically productive age group of 1 8-40
years of age. 25% of Hl V-infected are women. The disease has not spared children. The virus infects
approximately 30,000 newborn children. At least 120,000 children have been orphaned by the AIDSrelated deaths of one or both parents.
There are certain differences between the epidemic in India and in the Western world. The virus seen in
India belongs to clade type C vs. clade B which is more prevalent in the West. Transmission through
blood transfusions is decreasing. Transmission from mother-to-child is increasing. Intravenous drug
use is a major source of transmission in India.
General awareness about the disease and about modes of transmission is low. Reproduct i\ e tract
infections are on the increase. Changing social behavior patterns, sensationalism by the media, and peer
pressure all contribute to the adoption of risky sexual behavior.
Large numbers of migrant workers tend to engage in high-risk behavior when they are away from their
families. Economic necessity and gender inequality render sex workers vulnerable to acquiring the
infection. In the Northeastern regions of the country, intravenous drug use also contributes to
transmission of the disease.
Abuse of blood and blood products as well as unsafe blood bank procedures have helped to spreads
HIV. Similarly, unsanitary conditions in ante-natal facilities have caused problems.
The central government of India established a National AIDS Committee in 1986 and launched the
National AIDS control program in 1987. In 1992, the government established a new program and
6
changed the committee into a National AIDS control organization (NACO). It also formulated a policy
that involved a multi-sectoral approach that included involvement of non-governmental organizations.
NACO implements its policies as well as its activities through the different stale AIDS Cclls/societies.
Its activities involve program management, surveillance, research, information, education, and
counseling activities. It also undertakes initiatives to ensure safe use of blood, reduction of sexually
transmitted diseases (STDs), condom promotion, and interventions that can reduce the impact of the
disease.
The Catholic Hospital Associations formulated a policy on HIV/AIDS in 1997. Il has been conducting
various training programs through its members. Catholic hospitals have been in the forefront of
providing care for HIV/AIDS in the country. Catholic colleges have taken active part in the university
programs on AIDS control.
Some recommended interventions to deal with the increase of Hl V spread in India include the
following:
1.
Medical interventions like voluntary testing and counseling; integrated approach to health
care such as that implemented by many Catholic hospitals in the country; provision of safe blood
transfusions; treatment of opportunistic infections; de-stigmatizing people living with HIV/AIDS
(PLWHAs); reduction of alcohol and drug abuse; adoption of universal precautions in the health care
setting and safe disposal of medical waste.
2.
Social interventions such as integration of HIV/AIDS education in the school curriculum
from 3ld and 4,h standard grades and gradual sophistication of curriculum content in later grades;
promotion of AIDS days in parish youth programs; family education and support programs at the
parish level; social welfare schemes to increase economic capacity and assist the unemployed; targeted
work with certain groups engaging in high risk behavior, including commercial sex workers. I VDUs.
and gay men.
Response of the Church in the United States to the Situation of HIV/AIDS
Fr. Michael Perry spoke of the two documents issued under the auspices of the Bishops' Conference of
the United States. The first, The Many Faces ofAIDS, was issued in 1987 by the Administrative Board
of the Bishops’ Conference. The second, AIDS: A Call to Compassion and Responsibility was issued
by the plenary body of bishops. Both documents emphasize the need for an integrated response from
the Church and for provision of services and advocacy on behalf of those li\ ing with HIV/AIDS.
In recent years, the International Justice Committee of the United States Conference of Catholic
Bishops has made advocacy on HIV/AIDS as one of its top priorities. Focus of the advocacy efforts
includes promotion of additional funding by the U.S. government for HIV/AIDS efforts in developing
countries, insistence on provision of anti-retroviral medications at affordable prices for PLWHAs living
in developing countries, and promotion of strategies to reduce stigma and discrimination against
Pl.WHAs.
7
Catholic Relief Services, the overseas relief and development arm of the bishops of the United States
has made a major commitment to fund HIV/AIDS efforts, especially in Africa, Asia, and Latin
America.
CMMB AS A CATALYST FOR A FAITH-BASED RESPONSE TO HIV/AIDS,
by Dr. RAB1A MATHAL DrPH, MPH, MS, PhD, GLOBAL DIRECTOR OF PROGRAMS
CATHOLIC MEDICAL MISSION BOARD: A Global Leader in Faith-Based Organizations
•CMMB is a 75 year old US based FBO
•Exclusively providing healthcare to people in need worldwide
•Focusing on strengthening health of vulnerable children and women
•CMMB collaborates with in-country faith-based umbrella organizations like CBC1, CHAI, CARITAS
INDIA, RELIGIOUS ORDERS and Technical resource and professional groups like ST. JOHN’S
NAHS, SDF, CRLCNGI, and CDC
•CMMB bases its programs on national priorities and guidelines, within WHO protocols
CMMB HIV/AIDS INITIATIVES
•CHOOSE TO CARE 84 Projects through Southern African Bishops Conference for HIV/AIDS
prevention, care and support in South Africa, Swaziland, Namibia, Lesotho and Botswana
•BORN TO LIVE PMTCT
Global Initiative, including National Scale-up in Kenya
HIV/AIDS Religious Initiatives
• CMMB collaborates with umbrella, faith-based groups to build capacity of religious leadership and
communities
• CMMB helps to strengthen faith-based health care infrastructure, such as in hospitals and other
health care facilities
CHOOSE TO CARE: FOCUS
CAPACITY BUILDING AND INTERVENTIONS:
•HOME BASED CARE AND SUPPORT INCLUDING PEOPLE LIVING WITH HIV/AIDS AND
AIDS ORPHANS thru Feb 2003: 160,000 home care patients, 3900 treated in hospice facilities, and
2700 AIDS orphans assisted
•PREVENTION EDUCATION FOR COMMUNITIES, ESPECIALLY ADOLESCENTS thru Feb
2003: 360,000 youth reached
•SENSITIZATION OF CHURCH LEADERSHIP AND CHURCH COMMUNITIES thru Feb 2003:
98% of SA diocese reached with HIV/AIDS community-based programs.
8
•RELIGIOUS INITIATIVE FOR SENSITIZATION OF CHURCH LEADERSHIP UNDER
PLANNING
CM MB works with 350 FBO Partners in Global Initiatives in Over 100 Countries
CMMB’s Preparatory Work in India
•Consultations with CBC1, CHAI, St. John’s Medical College
•Meeting NACO and CDC officials with CBCI and CHAI
•Working on draft strategies with above organisations
•Supporting national PMTCT training for Catholic facilities
•Serving as a Catalyst for this meeting
CMMB stands ready to ...
•Work in collaboration with the co-sponsors of this meeting to promote an appropriate response to
H1V/AIDS in India
•Respond to needs as they are identified in India (beginning with this meeting)
•Assist Indian partners with capacity-building
•Establish an in-country office and identify leadership for this office
•Support additional regional meetings and consultations as planned
Dr. Mathai ended her presentation by thanking all the participants for their excellent contributions to
the discussion and by raising an urgent question: What will be our next steps????
HIV/A1DS and the Ethical Response of the Church
Rev. Dr. Thomas Kalam, Director of St. John’s National Academy of Health Sciences. Bangalore,
prepared an extensive paper on the ethical response to HIV/AIDS.
He said that Christ’s view of illness (that it is “for God’s glory” (John 11:14) and “so that God's works
might be revealed” (John 9:3) must be the basis for a Christian ethics of Hl V/AIDS.
He maintained that the ethics of HIV/AIDS cannot be confined to casuistry, even though this is a useful
instrument in detailing Christian moral response to a range of difficulties. The ethics of Hl VAI DS must
be developed with reference to the ultimate aim of achieving the fullness of life and thus the glory of
God.
Fr. Kalam insisted that the conjecture that AIDS might be God’s punishment for sin must be ruled out
at the very outset of our discussion. The virus can be transmitted in different ways, moral, immoral, and
amoral. It is primarily an epidemiological issues rather than a moral one.
He then detailed different ways in which HIV/AIDS has become an occasion for the promotion of the
fullness of life:
9
By celebrating life when it is disrupted by HIV/AIDS
In the positive living of people with HIV/AIDS
In the cry of those with HIV/AIDS
In the care given to people living with HIV/AIDS
In the efforts for positive action for prevention and education
Fr. Kalam said that ethical conflicts arising from HIV/AIDS can be grouped under three areas:
1. In dealing with People affected by HIV/AIDS: This ethics should promote the care and treatment
PLWHAs should get; it should guarantee strong action to protect individuals against discriminatory
treatment or any form of persecution of ill treatment; it should protect the human dignity of the
a fleeted.
2. In dealing with the general public not affected: it should positively address the need to protect public
health by helping to promote ways of preventing the spread of HIV/AIDS.
3. In dealing with enhancement of human life: it should enable everyone, both the infected and non
infected to “live positively” with this pandemic of HIV/AIDS. The quality of human life should be
enhanced in the way we deal with HIV/AIDS.
In the matter of HIV/AIDS, the poles of ethical conflict are:
Public health vs. Fundamental rights of an individual
Utility (for many) vs. Liberty (for the few)
One has to strike a balance which, while protecting public health, will also protect indi\ iduals so that
they will feel free to come forward for available treatment. Any one-sided and divisive approach that
sets fundamental rights of individuals in opposition to public health, or vice versa, or which does not
give hope to both the affected and non-affected cannot be considered as constructively ethical.
Use of Indian Traditional Drugs in HI VAI DS - A Scientific and Clinical Study
Drs. M. Kesavan and Kttan Tharakan presented joint papers on the use of traditional drugs in
HIV/AIDS treatment. Findings of their studies indicate satisfactory relief of opportunistic infections
and physical ailments in patients. Symptoms relieved included: fever, diarrhea, joint pain, itching, and
partial relief of lymphadenopathy. Medication improved the life span of the patients. Patients with
tuberculosis were referred for Western medical treatment as well.
Value-Based University Programs of Study on HIV and Family Education
Professor Gracious Thomas explained the Catholic Bishops’ Conference of India (CBCI) and Indira
Ghandi National Open University (IGNOU) signed a Memorandum of Understanding on February 29.
2000, to establish the 1GNOU-CBC1 Chair on “health and Social Welfare” al IGNOU.
10
One of the objectives in establishing this Chair was to develop and launch programs of study in the
areas of HIV/AIDS and Family Education. The “Certificate in HIV and Family Education” (6-month
study period) was established in January 2002. The Diploma on “HIV and Family Education" (1-year
study period) was established in 2003. The main target audiences for these programs are school
teachers. NGO staff, para-medics, and parents of adolescents. More than 2000 students are enrolled in
these programs.
Currently IGNOU is involved in a massive HIV/AIDS Awareness Campaign. The university has
de\ eloped a brochure entitled, HIV Prevention Guide, for its students; this is being mailed to 300,000
students and may eventually reach 1 million students this year. IGNOU has produced more than a
dozen video films and audio programs that are broadcast through various outlets. IGNOU conducts
regular teleconferences on this topic. The university also conducts awareness-raising seminars about
HIV/AIDS.
Proposed Common Policy Statement on HIV/AIDS by the Church in India
A preliminary draft of this statement was presented by staff of the CBCI Health Desk. The participants
complimented this effort and gave helpful suggestions for editing and change.
Plans for Future Activities
The participants made recommendations for future activities, including:
1.
Prevention Education and Awareness-Raising about HIV/AIDS
• Preparation of a Vision and Mission Statement to be issues by the Bishops of
India
• Training of Church leaders, especially bishops in a 12 seminar during the
Plenary meeting of the bishops of India
• Training of seminarians
• Training of diocesan social service directors (by Caritas India)
• Integration of HIV/AIDS education in school curricula
• Designation of AIDS day on one Sunday of the year for awareness-raising in
the parishes
• Integration of HIV/AIDS education in pre-marital preparation courses
• Train students, teachers, health care workers, men's and women's groups
2.
Care and Support
• Establish care centers as needed
• Disseminate CHAI policy guidelines to medical staff
• Include Post-Exposure Prophylaxis at all nursing stations in Catholic hospitals
1 I
•
Offer Church-sponsored financial support to needy PLWHAs and their children
3. Fight Discrimination and Stigmatization
1. Empower medical staff to use universal precautions with all patients, not just those
living with HIV/AIDS
4. Pastoral Assistance
• Train pastoral agents on pastoral care and counseling
5. Networking
• CHAI to prepare protocols to all member organizations on how to access State AIDS
society funding
6.
Planning and Strategizing
• Request religious congregations to include HIV/AIDS services in their respective charisms
• Establish a central section with a technical team to monitor Church-sponsored activities and
trends of the pandemic
Report Prepared by: Rev. Robert J. Vitillo, on August 29, 2003
12
198
cai hoi k; hthicists on hiV/'aids prevention
will come as a separate decision outside the context of the group. The
group is set up in such a way that it does nor encourage sexual behavior
per sc. It is hoped simply that the mutual support resulting from participa
tion in rhe group will influence rhe individual’s choices as regards to the
riming and manner of any possible future sexual beha’vior.
This seeking to influence a sexual act, should it take place, does intro
duce rhe element of cooperation. However, there is no expectation on the
parr of rhe group that the individual will or should engage in sexual behav
ior. Remoteness is also assured in the presence and purpose of support
staff: to discuss clinical issues of infection, assure that the dignity of the
topic is preserved, and offer the pastoral presence of the church.
On the other hand, it can be argued that rhe cooperative involvement of
ihe clinic is through its facilitation of a mechanism meant to influence individ
uals l<> make dv<.isions whether to engage in homosexual activit\. I urther, it is
also meant io influence the decisions of those who decide for sexual activity
regarding with whom, when, and in what manner. For rhe support group to
be effective, it must have a direct influence on rhe participants’ multifaceted
decisions regarding sexual behavior. This will include influencnthe persons
decisions both to abstain from and engage in sexual activity. If the person
chooses to engage in sexual activity, the hope of the group is that the decision
will be with greater discipline than might otherwise be exercised. From this
perspective, it can lx? argued that the cooperation is morally proximate.
I am nor certain that rhe characterization of rhe mediate material coop
eration as proximate or remote is always helpful, especially in cases like
this in which the cooperation can be characterized as being either one or
the other. I he question is not so much whether rhe cooperation is proxi
mate or remote, hut whether morally permissible cooperation is prudent.
I bar is to say, whatever proximity or remoteness is present, is it—in light
of the moral gravity present, the eml being sought, and the duress shaping
(he situation—reasonable to proceed?
Characterizing the cooperation as proximate or remote may be helpful
m discerning the prudence of doing so, but rhe characterization itself is not
definitive. Simply because the cooperation is remote will not necessarily
mean it is prudent to proceed, and likewise rhe fact that it is proximate will
not necessarih mean it is imprudent to do so. What is more important is
that there be ; comfortable fit with the cooperation and the identiry/mission of the institution. In light of (he church's teaching regarding the homo
sexual person, as distinct from the homosexual activity, its concern for rhe
individual and common good, and the absence of more readily available
means, it can be judged prudent to form the support group, however the
moral dislamc is characieiized.
l inall), then
ihc qmsiion of scandal. Scandal should not be an issue
h>i those wl
uh«» midi island the history and format of the group. I hc
199
CATHOLIC HOSPITAL IN INDIA . .
I
l
I
disclaimer at each meeting also makes clear the beliefs and role of rhe
Catholic sponsor of the clinic. In addition, the concern for scandal can be
minimized if one keeps in mind that the gay men who participate “must be
accepted with respect, compassion, and sensitivity. Every sign of unjust dis
crimination in their regard should be avoided” (CCC 2358).
It should also be admitted that the risk of scandal does not exist sole
ly when cooperation in wrongdoing takes place. There may also be a risk
of scandal in the failure to offer the same resources and opportunities to
develop the virtue of temperance in the sexual lives of the homosexual per
son as offered to others, even if doing so requires some mediate material
cooperation in wrongdoing. If one looks at the support group within the
larger perspective of the church’s mission to lead all people to holiness, it
may be that this mediate material cooperation is to be preferred over the
alternative of doing nothing in a way not dissimilar from Pius Xll’s state
ment that it is sometimes preferable to tolerate rather than oppose wrong
doing.7 As the Catechism states,/*by the virtue of self-mastery that teaches
inner freedom, at times by the support of disinterested friendship, by
prayer, and sacramental grace,” the homosexual person can and should
gradually and resolutely approach Christian perfection” (CCC 2359).
Through mediate material cooperation in homosexual activity, this support
group may do more than reduce the incidence of HIV infection among a
targeted audience. It may also facilitate the gradual but resolute pursuit of
Christian perfection.
A Cathoik: Hospitai in India is.
Cooperate with an HIV Pria'idas
to
Program
Clement Campos, C.Ss.R.
.■ .I'ermnental orgaA GROUP OF religious sisters were approaches
- their hospital. This
nization (NGO) for the use of an unoccupied .c \ :
■ ’ • jraoHg people with
organization wished to use the premises tor li'-.'oIt was brought
HIV/AIDS. Initially the sisters appeared opto: i
. .. : the adihcc of the
to their attention, however, that the organizati.
shifitld be offered to
World Health Organization that “a range oj otnu
7. Pius XII, Ct ncscc, AAS XX (1953): 79X-S I !
CA
200
. I
CATHOLIC ETH1CISTS ON II1V/a1DS PREVENTION
I
CATHOLIC HOSPITAL IN INDIA .
201
This case is illustrative of one of the major dilemmas facing Catholic Church
institutions in India in their response to the AIDS pandemic: To what degree
may they be involved in ministry among people with AIDS, especially when
their involvement necessarily includes cooperation with groups that do not
share the same vision as the Catholic Church and, in fact, use means that
the traditional teaching of the church considers immoral?
In this study we shall first look ar the situation in India and then briefly
see the response of the church before addressing rhe major ethical issues
raised by this particular case.
four million adult HIV infections, the highest in the world, with one million
new infections every year. It further states that nearly 30,000 newborns arc
infected and 20,000 die every year due to HIV.2
“A Strategic Plan for Prevention and Ckintrol of AIDS in India was pre
pared for country-wide implementation for the period 1992 to 1997, but it is
hard to determine the impact and effectiveness of these programs? From time
to time the media carry reports of the failure of the authorities to deal with the
pandemic and the appalling lack of awareness among the population.
It must also be noted that insurance in the health field for both patients
and medical professionals is restricted to a small group. While the poor
may have access to the government-run hospitals free of cost, the quality
of care and the reliability of tests leaves much to be desired.
There are a number of incidents of violence against AIDS patients?
This is the result of fear that arises out of a lack of education. At the same
time a serious study analyzing household and community responses to HIV
in predominantly lower income households and communities in greater
Mumbai (Bombay) indicates a supportive and positive attitude toward peo
ple with HIV/AIDS.5
The Indian Context
The Church’s Response
It is very hard to establish the extent of the spread of HIV/AIDS in India.
The National AIDS Control Organization (NACO) reported that as of 31
March 1999, our of 3,457,080 samples screened, there were 7,012 cases of
AID^ and 85,312 were confirmed HIV seropositive. The seropositivity rate
is 24.68 per thousand. The epidemiological data indicate that the prevalence
of HIV continues to increase and spread mostly through the heterosexual
route, from the urban to the rural areas, and from the individuals practicing
risk behaviors to the general population. Critics point out that these figures
arc flawed, because the samples do nor cover all rhe states and the survey
has been mainly limited to high risk groups—sexually active women attend
ing prenatal clinics, and men and women attending clinics for sexually
transmitted diseases. The figures refer to people tested and not to the entire
population. But even making allowances lor.these drawbacks, the picture is
grim. There is a great deal of under-diagnosis involved and the real figures
arc nor showing up in hospital records.1 Another study states that there are
The Catholic Church in India is comparatively small. Numbering close
to 15 million, it makes up just 1.51 percent of a population that is fast
approaching a billion. The entire Christian population is about 2.3 percent
the
of the total population. Yet the contribution of the church, especially in t!..
yonn^ people, inclnding postponing the first sexual activity and, for those
already active, nonpenetrative sex and the use of condoms for protected
intercourse." One of the stated objectives of the organiziition tvas "con
trolling and containing the spread of IIIV infection among a defined vul
nerable target population, through education, awareness, and the
promotion of safe sex. ” The sisters then sought the advice of some Catholic
experts and eventually decided not to place their property at the service of
this group.
1. For example, an analysis ofr Mumbai’s mortality data for 1994 showed an
abnormal increase in deaths due to tuberculosis, diarrhea, and hepatitis (infections
common among HIV-positive people), especially among young adults and
teenagers. Express Magazine (13 September 1998): 4.
I
2. UNAIDS, Geneva, 1998.
3. Tnc aims were to establish a program which would prevent HIV transmis
sion. decrease the morbidity and mortality associated with IIIV infection, and min
imize ti.. socio-economic impact resulting from HIV infection. These goals were to
be aeinexed through meeting a series of medium-term objectives: a)To establish
effective surveillance in all states to monitor the epidemic; b) To provide sound
technic:’ support; c) To ensure a high level of awareness of HIV/AIDS and its pre
vent!-.
•■■■■ population; d) To promote the use of condoms; e) To target intcrvunum...... groups identified as high risk; f) To ensure the safety of blood; g) To
develop tir. services required to provide support to HIV-infected persons, AIDS
patient . .u
their associates. See National AIDS Control Programme, India:
Coionn scenario, An Update, published by the Ministry of Health and Family
Weirarc. Government of India, December 1996.
4 • limes of India, 13 June 1998, 12.
?.
Bharat, Facing the Challenge: Household and Community Response
HIV AIDS m Mumbai, India (Mumbai: Tata Institute of Social Sciences, 1996).
4
202
catholic
i rmcisT S on
field of health care, is quite significant. It is estimated that the church hos
pitals, dispensaries, and health centers provide about 10 percent of the
health care in the country. With the Governmental Health Care system in
India proving grossly inadequate, the burden of looking after the needs o
the poor often falls on voluntary agencies—those that belong to the church
and other religious organizations as well as nongovernmental organiza
tions (NGOs). Ar present the NGOs seem to be taking the initiative in
responding to AIDS. On an institutional level the church has not done
much. But with its modest resources, its contribution can only be limited.
What is required, apart from ministering to people with AIDS who come
to their institutions, is networking with governmental and other secular
agencies?’ The Catholic Hospital Association of India (CHAI) in its policy
statement has in fact recommended working with other agencies. But it is
precisely here the church faces a conflict. How is it to cooperate with agen
cies that promote responses not in keeping with the teaching of the church?
More specifically, how does the church cooperate with agencies that make
the use of prophylactics an essential part of their response to AIDS? These
questions do not seem to have been addressed either by CHAI or by the
bishops of India. A recent consultation of church bodies held in Delhi in
April 1999 dealt with some of these issues with many participants, repre
senting groups involved in ministry to people with AIDS, seeking direction
and support from church leadership to respond to this thorny hut urgent
pastoral problem.
In its response to the AIDS crisis, the church has to combine prophet
ic witness to the truth with pastoral compassion. 1 he compassionate face
of the church in India has traditionally been revealed especially by the char
itable hospitals, orphanages, hospices, and developmental activities that
are mostly run by religious. I he church also has the reputation of normal
ly being the first to respond to major natural calamities. Yet in the face of
rhe HIV/AIDS pandemic there has been a certain reluctance shown by
church personnel to get involved.
Two reasons haw been suegested by them in private discussions. First,
there is a certain amount <»t <.hsc<»mtort and uncase in relating to rhe Hl\uitecred persons because one is not comfortable with rhe subcultures to
which manv belong—the gav community, commercial sex workers, drug
addicts. Second, there is a conflict betwecirthc views of the church and the
programs of other agencies, especially with regard to the use of condoms,
which makes it difficult to get involved in this ministry.
6. Pope John Paul I! has also stated that rhe struggle against AIDS calls ior col
laboration among all people. Daiottimn Hanuninn. Church, and Health m the
World 5.1 (1990)
CATHOLIC HOSPITAL IN INDIA - -
hiv/aids previ-n iton
203
With regard to the first reason, what is required is thatt one learn to dis3 morally inappropriate bchnvtinguish between compassion and condoning
the basis of moral behavior as
ior. Compassion does not discriminate on d
Jesus showed in his ministry. The second reason raises a problem that needs
to be addressed. To deal with this issue, we will examine first the ethical
problem of “safe sex” and then deal with the response of rhe church on (he
I
i
individual and institutional levels.
The Issue of Condoms and Safe Sex
Safe SEX SEEMS to be the major agenda of politicians, scientists, and the
media. In India this is part of the official strategy to combat AIDS. I he
guidelines underlying this proposal are twofold: to avo.d sex w.th people
likely to pass on the infection, and to use condoms when there is a risk, he
criticism generally leveled against this approach is that while the condoin
is effective to some extent, it does not guarantee complete protection, and
it is wrong to speak of it as safe sex. Moreover, this approach tends to
encourage irresponsible sexual behavior. Technical solutions ignore the
root causes of such behavior.
ir is important that the church take a prophetic stand against the state
when it advocates safe sex through public advertising and promotion and
distribution of condoms, it must be conceded that the state has the duty to
rake necessary measures to a\ nd the spread of the epidemic, always keepmg in mind the right of the c o. cn ro privacy and the right to civil toler
ance. But for rhe state to advo..m and make available prophylactics is to
run the risk of encouraging irresponsible moral behavior, and in fact expos
ing society to widespread difiusion of the contagion. It is not the state’s
objective of containing the comacion that is being disputed, but the means
which are technically in.>ufncantiy reliable and morally questionable.
The church’s appro •
ro suggest sexual abstinence for unmarried
people and fidehtv
c
o ers within a monogamous and indissolu
ble marriage Acc-'U-.nliuonal reaching of the church, the use
of a condom as .> . m; :
.
• immoral. Moreover, in the context of the
AIDS pandenu
-nso critical of the promotion of condom
usage as part of o
. unpaign. But, in a country that is as cul
turally diverse and . cue.
mdisticashidiaDheC^thiilicpastcu/ccmnselor/physician is
v.iih several difficulties in putting across this
is conn
coni:mm.
...
point of view.
7. Carlo Caffarra. ‘ A!: > General Ethical Aspects/ Dolcntium
bS-72.
204
CATHOLIC LT HI CISTS ON HIV/aIDS PR EV I-NT I ON
CATHOLIC HOSPITAL IN INDIA . . .
205
4
Problems on the Level of Individuals and Institutions
The government has for many decades strongly advocated family plan
ning. Apart from the objection to the use of coercion, the vast majority of
Indians do not have any ethical objections to the use of contraception, ster
ilization, and even abortion. Hence, on an individual basis, it is not easy to
convince people of the rightness of the Catholic position with regard to the
use of condoms. In fact, it appears difficult at times to convince Catholics.
I here have been reports of religious distributing condoms as part of their
ministry among commercial sex workers and people with AIDS. They
seemed to justify this as a way of limiting the extent of evil when individ
uals refuse to desist from irresponsible moral behavior.8
There is also a problem on the institutional level. In the case cited at
rhe beginning, we saw the difficulty in being associated with groups work
ing for people with AIDS but promoting the distribution and use of con
doms. ‘ International funding agencies also often make rhe distribution of
condoms one of the requisites for obtaining financial help. To what extent
and in what manner can a Catholic or a Catholic institution get involved?
1 he response of the Catholic Church should be on two levels. Ir must
bear witness to the inclusive nature of its compassion, protesting against
discrimination by a broad policy of acceptance of people with AIDS and
providing care. It must further be involved in the task of “responsibilizanon”—educating people to responsibility especially in the areas of preven
tion, transmission, and healing.10
Educating Individuals to Responsibility
In THI TASK of educating people to responsibility, we must he clear about rhe
content and limits of our teaching. In Catholic institutions one is bound b\
what the Catholic Church regards as a Catholic vision and a Catholic ethic
8. .At rhe National Qonsulration of Catholic Church Bodies mention was ais
made of such incidents as providing clean needles to drug addicts to prevent Hl\
jntrcrion.
9. This also seems to have been rhe view of Archbishop Roger Mahoney who
wimdrew permission for the use <»l church facilities tor an AIDS education program
wlmh he discovered would promote the use ol condoms. Or/g/ns 16.28 (1986): 50e
10. Marciano \ idal suggests that the two basic criteria of the ethics of AIDS
arc responsibihzation and ‘‘nondiscrimination.” Sec 1 he (Tristian Ethic: I lelp
nr ilindrancc.' I he I'.tlmal As|Hrcts of AIDS,’ |osc Oscar Beozzo and Virgil
Elizmndo, eds.. Com tluor. The Return o/ the Plunuf (1997/75): 89-98,
What happens when one is confronted widi a person or a group of per
sons who belong to another faith or who do not share the same ethical val
ues as the Catholic? I believe that guidelines must be clearly given so that
Catholics know what is expected of them. With regard to the prevention of
the spread of AIDS, the U.S. bishops provide a useful indicator of a possi
ble approach. Facing the ground realities, they suggest that educational
efforts, if rooted in a proper moral vision, could include accurate informa
tion about prophylactic devices or other practices proposed by medical
experts. They clearly state that they are not promoting the use of prophy
lactics, but merely providing information. They do so only after a critique
of “safe sex” and an insistence that chaste sexual behavior and avoidance
of intravenous drug abuse are the only correct and medically sure ways to
prevent the spread of AIDS.11
Problems of Cooperation with Others
With regard to the problem of collaborating with other agencies that
promote and distribute condoms as part of the strategy, the answer to these
dilemmas may be found in the traditional principle of moral theology—
namely, the principle of cooperation in evil.
In using the principle of cooperation it is important to keep several fac
tors in mind. To state that we must be careful not to cooperate in or pro
mote actions of others when those acts are immoral is, in a sense, to state
the obvious. But life is not so simple. We are called to live and carry out
our mission in the world and the real world is complex. It is a world of
interdependence and ethical pluralism, a world where good and evil coex
ist. It is not always easy to pursue the good without in some way incurring
some degree of evil. One cannot opt to withdraw totally from the world in
order not to be contaminated by evil. That would involve an inability to do
.my good as well. Yet, if we even appear to compromise, we can scandalize
people by giving them the impression of involvement in evil.
The traditional doctrine has been clear: it is always unethical to cooper
ate formally with an immoral act (intend the evil act itself), but it may be per
missible to cooperate materially with an immoral act (only indirectly
unending its harmful consequences) when only in this way can a greater harm
be prevented, provided that (1) the cooperation is not immediate and (2) that
tiiu degree of cooperation and the danger of scandal arc taken into account.'-
11. L’SCC Administrative Board. “The Many Faces of AIDS: A t.ospcl
Response.” ( hiatus 17 (1987): -182-89.
12. j.lines I. Keenan has suggested that we keep in nnnd some preliminary
insights before appealing to the principle. It ts a guiding principle and not a
207
CATHOLIC ETHICISTS ON Hiv/AIDS PREVENTION
CATHOLIC HOSPITAL IN INDIA . . .
In the light of this doctrine, How would one make a moral decision in
the case given above? As James F. Keenan suggests, at least six questions
must be answered to determine whether A can legitimately cooperate with
B. “First, what is rhe object of A’s activity? Second, is A’s cooperation in B’s
illicit activity formal or merely material? Third, is the cooperation imme
diate or simply mediate? Fourth, is the cooperation proximate or simply
remote? Fifth, does A have sufficient cause for acting? Sixth, is A’s cooper
ation indispensable?”11
Applying this principle to the case given, we might draw the following
conclusions:
1. In the matter of renting rooms for rhe NGO, we could say rhe object
of the sisters’ act would not in itself be immoral. They merely provide space
for the care of people with AIDS.
2. The cooperation is nor formal because they do not show approval of
the use of prophylactics or intend the act. It is possible for them to detach
their concern for people living with HIV/AIDS from the use and promotion
of condoms which they do not intend. Such cooperation is only material.
3. Their cooperation is not immediate, since the object of their action
is not the same as the object of the illicit activity, nor are they involved in
any essential part of the illicit activity.
4. Further, the cooperation is remote from the illicit activity. The act
of renting out space is radically different from the acts of the religious
who decide to distribute condoms to commercial sex workers and people
with AIDS.
5. Yet another question that is traditionally asked is whether there is a
sufficiently grave reason for the cooperation. Taking into consideration the
nature of the AIDS pandemic and rhe urgent need to provide care and pre
vent an epidemic in the interest of the common good, one could claim that
there are sufficiently grave reasons.
6. We may also state that rhe cooperation is not indispensable to the
performance of rhe immoral act.
7. But one final factor needs to be taken into account—namely, tn-,
danger of scandal. It is precisely this factor that seems to have prevents.
the sisters from renting out their premises. It could be interpreted as an
endorsement of an approach that was at variance with the official stance of
the church insofar as their building was being used for the promotion and
distribution of prophylactics for people with AIDS.
Could this problem have been resolved positively? Perhaps an alterna
tive may have been to ensure through a contract that in this instance, the
organization would limit its work for people with AIDS in such a way that
usage of condoms would not be promoted at this center. In this manner, the
sisters would have shown support for the good work done by the organi
zation for people with AIDS while publicly showing disapproval of the pro
motion of “safe sex.”
But it should also be clear from the principle that distribution of con
doms by Catholics either as a way of preventing infection or in order to
obtain funds for caring for people with AIDS does not meet the criteria for
legitimate cooperation and cannot be morally justified. The reason is that
the cooperation is so immediate as to almost make them primary agents.
A further question needs to be asked: Would networking with these
agencies be construed as unlawful cooperation in evil? Could individual
Catholics be involved with these groups in working for people with AIDS?
It would in fact appear to be easier to justify these cases than the cases just
dealt with. Provided it is clearly indicated that one distances oneself from
the promotion and distribution of prophylactics, one could legitimately
cooperate with such agencies as an effective way of promoting the good. It
would be an effective way of making the Christian presence felt and the
Christian voice heard in this area. It would be possible through counseling
and education to limit the damage done by these agencies—NGOs or stare
agencies. There is support for this approach in the traditional teaching and
the pastoral practice of the church.14
It is important that the church issue directives along these lines so that
its members and institutions can more actively respond to the AIDS crisis.
206
Social Dimension
BECAUSE OF THE attention constantly given to the issue of prophylactics, the
impression often created is that AIDS is essentially an issue of sexual
permitting principle. It is a principle that we avoid as far as possible because coo:
eration in evil is regrettable. One of the purposes of the principle is to contain en
The principle cannot be used mechanically, but has to be applied with human rea
soning. James F. Keenan, "institutional (.Cooperation and the Ethical and Religion
Directives,” Ltnacrc Quarterly 64 (August 1997): 53-76.
13. James l;. Keenan, “Prophylactics, Toleration, and Cooperation: (Conteinp< rary Problems and Traditional Principles,” htlcrnaliothjl rbilasophical Quarter!
29’(1989): 209.
l
14. One example of an attempt to limit evil is provided by E^angeliurti Vitae
73 in rhe area of the civil law on nliortion. Keenan also mentions cooperation
implied in the involvement of rhe Vatican’s institutional engagement of other insti
tutions, some of which entail evil—concordats with other states, involvement in
agencies like rhe U.N.—agencies that do not always promote what the Vatican con
siders morally right. Keenan, “institutional Cooperation,” 62.
208
CATHOLIC ETHICISTS ON Iliv/AIDS PREVI-N ITON
i
(M HOI.IC HOSPITAL IN INDIA . . ,
209
i
morality. It is nor. It is more an issue of social justice, involving human
rights and the conflict between the rights of the individual and the protec
tion of the common good. Ebe Christian response must be on both the
micro and the macro levels.
There is a need for the practice of what Vidal calls “nondiscrimina
tion," stated more positively as the criterion of inclusion or solidarity. The
starting point is the criterion of acceptance of the other whom I cannot
“shut out" but whom I must “bring in” in a special way to the dynamic of
solidarity of human actions.15 India has had a long history of discrimina
tion that included a practice known as “untouchability." Untouchability
was formally abolished in the Indian Constitution, no. 17, but discrimina
tion still continues. There is a danger of people with HIV/AIDS becoming
the new untouchables. The reason is that the disease carries a social stigma.
In rhe public perception persons living with HIV/AIDS arc seen as having
brought it on themselves by immoral behavior. As a result people with
AIDS are discriminated against in the area of employment, housing, and
access to health care. At times they are denied basic rights such as liberty,
autonomy, and freedom of movement. This constitutes an attack on the
foundations of justice based on the equal dignity of all human beings, and
violates the claim to just and lair treatment irrespective of a person’s phys
ical condition or the cause of it.16
The Catholic Hospital Association of India (CHAI) has rightly decid
ed that health care institutions have an obligation to establish a policy that
guarantees optimum care, resist. ..r.. : rn; ot discrimination, helps in pro
moting research, and provides coticaiioiiai and counseling support. As Dr.
Edmund Pellegrino suggests, the! . ■ .list) a collective responsibility to reaffirm the obligation of all docn>i- i- treat HIV infection, to take action
against those who do nor.
.•■'oort physicians who have become
mkvtcd. I he prolcssion has
tmcncc on society and should be an
advocate lor nondiscrnnina:
; assionatc, and competent care of all
HlV-infected patients.'~
Unfortunately, despii •
nes of CHAI that stare that no one
must be denied admission •
• :n hospitals because they suffer from
15. Vidal, “Christian 1;;..,.
16. Gauduon et Spes cicarr
....... Decause of the dignity proper to human
persons their rights and duties
.>■ and inalienable. It further declares that
every form of discrimination. wnrtr.r social or cultural, whether based on sex,
race, color, social condition, ianru... or religion, is to be overcome and eradicat
ed as contrary to Gods will in.
.J
A similar statement can be found in the
Lhtit'crsiil DecLiniiion of Hioh,o:
1“'. Edmund Pellegrino, 1’Trc.macn: Decisions and Ethics in HIV infection."
Doiemitmi Honiinmn. I 16-17
I
H1V/AIDS, some institutions are reported to have flouted these norms and
turned away people with AIDS. This is ethically unacceptable. The reasons
usually given arc fear of contracting the disease, lack of protective equip
ment, lack of insurance coverage, or the fear that other patients will keep
away due to the fear of contracting AIDS. From the physician’s perspective,
this goes against all the basic principles of medical ethics (beneficence, non
maleficence, respect for persons, and justice). Ignorance accounts for much
of the attitude of fear. People are afraid of what they do not comprehend.
However, this cannot be an excuse for violent or discriminatory behavior
against those who are infected. While individuals have the right to reason
able protective c< ver in terms of procedure, gear, and insurance, as well as
protection from infection, this cannot be done in a way that dehumanizes or
victimizes those already infected.
As Pellegrino points out, the physician’s primary obligation is to treat
the sick without discrimination. I le grounds this duty in the nature of med
ical knowledge and the covenant physicians enter into with society when
they accept a medical education and take an oath of commitment to the care
of the sick.18 There is a fiduciary relationship that exists between physician
and patient that justifies the invasion of the patients privacy.To refuse treat
ment violates this relationship. Medical care is not a marketable commodi
ty in the sense of being a matter of price and quality and distribution, and a
physician is not free to deny care to a patient in need of it. Medical knowl
edge is nonproprietary, and doctors also enter into a social covenant with
society for a social purpose. It is this that enables them to acquire knowl
edge gathered from all patients by all physicians.
It is also society that largely supports their education. Society has a
rightful claim on the services of physicians in public emergency. The med
ical professional enters into this covenant to provide a service that at times
involves some risk. I he covenant cannot be nullified Ixxausc ol a danger
now present—very much as a fireman or policeman cannot refuse to help
because of danger.19 Catholic physicians and medical institutions must give
the lead in this regard.
The conflict between individual rights and the common good is seen in
the development of programs to control, reduce, or eradicate AIDS. One
such area is that of mandatory testing of individuals and mass screening.
Only if some proportionate health or medical objective is being served, can
such an invasion of a person’s right to autonomy and right to privacy be
18. Pellegrino, “Treatment Decisions," I 13.
19. Pellegrino’s arguments published elsewhere have been summarized by
Richard |. Devine, (itnul Cairr. Pcibtful Choices: Mrtiicdl Ethns for Cirduhiry
People ( Mahwah, NI.J.: Paulist Press. 1996), 16.3-64.
210
(' A I 11 < ) I. I (' I TH l C I S IS ON
In the context ot I mi:
to collaborate w ith govri
it is important to clcarix
HIV/A1DS present
genuine healing and
truth, vet unafraid •
allowed. But the fact that this often leads to further discrimination and
denial of health care, and that at present there is no therapeutic benefit to
the patient, indicates that there is no justification for such mandatory
screening or resting.
Another area concerning justice is rhe allocation of resources. The
exorbitant cost of providing care to people with AIDS places a strain on
society. There is sometimes an objection made that society is not obliged to
provide for people who have freely brought the disease on themselves
through their behavior. However, this would also constitute unjust dis
crimination. Access to health care is a right for all persons. There is also a
global dimension to be kept in mind. The distribution of resources for the
treatment and care of AIDS patients and the prevention of HIV transmis
sion has been extremely unequal. Although more than 80 percent of all
HIV infections occur in less-affluent countries, they receive only a small
portion of rhe international resources spent on HIV/AIDS. This raises a
serious issue of distributive justice.20
As the study document ot the WCC indicates, socio-economic and cul
tural contexts are determining factors in the spread of HIV/AIDS. The
WHO currently estimates that nine out of ten people with HIV live in areas
where poverty, the subordinate status of women and children, and dis
crimination arc present.21 Apart from its response to the immediate effects
and causes of HIV/AIDS, the church, conscious of the link between pover
ty and AIDS, must continue to promote just and sustainable development.
It also needs to pay attention to situations that increase vulnerability to
AIDS—migrant labor, commercial sex activity, and the drug culture. Finally
it must also stand up for rhe human rights of persons living with HIV/AIDS
who are often denied their fundamental right to security, freedom of asso
ciation, movement, and adequate health care.22
20. Iiichiii AIDS: The (bdllcn^c, the C.burch's Rcsltonse, WCC^ Study
Document (Geneva: WCC Publications, 1997), 66.
21. Facing AIDS, 13. According to Dr. Elizabeth Reid, “it is critical to explore
the relationship between economic, social, and cultural variables and the spread of
HIV—who becomes infected with the virus and with what spatial distribution.
Examples which have been identified as having"a causal role in the spread of the
virus include gender (more specifically the economic, social, and cultural lack of
autonomy of women, which places them at risk of infection); poverty and social
exclusion (the absence of economic, social, and political rights); and labor mobili
ty (which is more than the physical mobility of persons and includes rhe effects on
values and traditional structures associated with the processes of modernization).
At rhe core of the transmission of HIV are issues of gender and poverty.” Quoted
in Facing AIDS, 14.
22. Facing AIDS, 95, r05.
INDIA
<: a r i h -1 :
II I v A I DS PR TV I N II ON-
to rhe people ot out
!
21 I
lurch cannot do this on its own. Il needs
; and other secular agencies. I hat is wh\
•isn ethical guidelines for such cooperation.
in India with a challenge to become a
immunity, boldly hearing witness to the
>wn theory and practice, and revealing
is.'.km ot
God.
CHAI’s Effort to Deal with HIV/AIDS
Involvement with HIV/AIDS work
As HIV/AIDS was becoming a serious health and social problem, there was an urgent cry from all
quarters of the church to respond to this grave situation. Since CHA! is the structural body responsible
for health, everyone looked up to CHAI for guidance and direction on HIV/AIDS.
Milestones of CHAI’s growth with specific focus on HIV/AIDS
1993
AIDS Desk was formed “ I hink-tank” group
1994
CHAI’s Policy on HIV/AIDS
-1995
CHAI’s Plan on HIV/AIDS
1996-1997
Personnel from the member institutions were trained to plan and initiate actions in
their regions
1998-2001
- Developed human resources in care and support.
- Networking with like-minded organizations for policy lobbying and advocacy.
2002 - 2004
The quality of life of the persons infected & affected with HIV/ AIDS is enhanced
through a process of specific interventions such as implementers forum &
promoting access to parallel system of medicine.
Specific Areas of Involvement:
CHAI approached the situation at various levels
Prevention
Training health care and social care professionals
Thrust Areas
Networking
Policy
Continuing Educational Material
Prevention
Prevention had been an utmost concern. CHAI had done pioneering work in the
area of school health. Developed modules and innovative approaches for Life
Skill Education in schoois ad colleges with the collaboration of CRI In 19971999.
Now we have been invited by Andhra Pradesh State AIDS Control Society to be
the nodal agency for the school health programme in the state of AP for the non
government schools.
Training
Training of the health care personnel with specific skills on prevention,
counselling, care and management. About 650 persons have been trained and
about 50% of them are directly involved in giving care while others have initiated
activities along with their ongoing work.
Training Programmes &
Participants trained
Short Courses
25%
Care &
Management
7%
iAS
Policy
36%
S
IM
Counselling
14%
\_Skills in care
18%
Networking
Networking with church related institutions, NGOs and Government agencies - such as APSACS for
the school health programmes “Life Skills Education” and Drop-in Centers”.
TB and Malaria Control Programme through the regional units. Training on microscopy through
Government agency.
Collaborating and networking with other Churches for care and prevention Community Health Watch
Groups.
Policy: Consultations were organized at Regional and National level to form policies.
1 .Common church policy
Intensive efforts had been taken to network and collaborate with church bodies, church related
institutions and NGO’s to bring out a common church policy on HIV/AIDS. Prevention, care,
management, counselling and training of personnel. This policy
would be available in six months.
2. Congregation and institution policy
Esl'pJss
Jtexifcte, to
jjWPBPrtgft
organized.
(St. Ann’s of Luzen sought help in developing the policy and now they have started a center in
Vijayawada, Andhra Pradesh for both men and women with HIV/AIDS).
Continuing Educational Material
Through our interventions, there was a felt need for scientific and updated information among our
membership. Personnel who have been trained by us are updated with the recent developments with
continuing educational material on HIV/AIDS and the concerns and issues. This material is sent once
in four months.
Impact
Nine years into HIV/AIDS work - we stop to look back and see if we have made a dent in the epidemic.
Has our mission of Christian love reached to the forsaken one?
\Ne feel content enough to say YES!I We made a dent in this epidemic through our love, service, and
efforts.
The approaches and strategies used during the past nine years in the areas of prevention, training,
networking, impact on the policies, and disseminating information enabled us to be instrumental in
starting 35 organizations/ institutions in India for the care, support and management of persons infected
ana affected with HIV/AIDS.
Organisations working for H IV/AIDS
Research
Oraganisation
Children
9%
Hospitals
23%
Hos pice
4 8%
Integrated
Approach to
HIV & TB
6%
Community
Based
Approach
11%
Back in 1993 when the challenge of HIV/AIDS was hurdled at us, there was not even a single church
related institution for the care and support of these most neglected and rejected ones. But today we
are glad to see 35 institutions giving these services. One young sister from Mumbai says that she feels
it is enough if we can allow them to die in peace and dignity.
Institutional care has always brought criticism about the sustainability, feasibility and impact in the long
run. However, when we look closely we found the impact the institutions have made:
X The institution facilitates acceptance in the community.
The local community contributes in caring for persons with HIV/AIDS through volunteering to serve
or meet their needs. Thereby through this process remove stigmatization.
The organization facilitates to build back the lost relationships of the persons with their family and
community.
Promotes dignity of life.
X The experiences shared by our member institution working with HIV/AIDS have shown that
institution/ organizations are instrumental in fostering community support in the course of time. (eg.
Jyothi Terminal Care center)
The membership involved in HIV/AIDS works were initiated based on the needs of the people. The
situation differs from state to state thus each organization is a unique model by itself. Some of them
focus on children while others care for men and women.
Few approaches that have made difference.
Integrated Approach
Mukta Jeevan now has an integrated approach to communicaoie diseases. The pioneer institution by
sisters of Helpers of Mary in Thane was started for the Leprosy patients. After the outbreak of HIV/AIDS
as some of patients also are with HIV. The management adopted a mainstream approach to patient
care. Patients whether with leprosy, TB or HiV/AiDS are isolated neither among themselves nor from
their families and friends. The caregiver and visitors take universal precaution in the care and
management of the inmates who live as a family there. There are men, women and children with and
without infections.
The families are supported to earn their livelihood through various income generation programmes.
The children are sent to the local schools.
Community involvement
Jyothi Terminal Care Center - A hospice was started two years ago in Mumbai has about 40 inmates.
There was a stiff resistance from the local community. They have even requested the hospice to be
shifted. However, over a period of six months, the community observed that the patients were cared by
the caregivers without fear or stigma. The carers also started going into the community and sensitizing
them. The response was overwhelming.
The organization is now run solely on local contribution, which even includes food, clothing and
medicine. The iocai community takes care of the dead. They perform the last rites according to the
patient's wishes. The women folk of the community volunteer their services in the kitchens. A place,
which was started as a hospice, has generated such a large community response.
Implementers Forum: A forum of organizations is envisaged at regional level of the members involved
in HIV/AIDS related work. The main aim of the forum is to:
X Training and enhancement of skill development
Establishing linkages/network with others working for HIV/AIDS
X Collaborate for specific issues such as gender sensitivity, care and support
Updating and sharing of resources - material and man power.
Support and care of the caregivers.
Some of our learning and challenges over the nine years are:
•
•
•
•
As India is a vast country having different cultural, the problems presents and the approach needs
to different.
A sionificant finding is that the training programme enabled the members to address the concerns
of the HIV/AIDS.
There has been an attitudinal change among the membership and a considerable shift in the policy
regarding admission for treatment.
Some of the membership has made a shift from institutional care to community based care, which is
foreseen as a positive development towards the mainstreaming of the persons infected and
affected with AIDS.
New initiatives
>
Based on our learning, the new initiatives envisaged are:
>
Implementers forums
>
Integration of HIV/AIDS to communicable diseases
>
Research and promotion of parallel system of medicine
>
Training on care and management
>
Research documentation
Through the initiatives
We hope to evolve care and support from the community-based organization and providing basic
care and counselling at home.
To establish much stronger network with national and international agencies working in this field
to mobilize a massive effort against HIV/AIDS to meet this challenge adequately, efficiently and
ciieutiveiy.
*****!**************★
/
/ /
■4" Missionsarztliches Institut Wurzburg
fW; Medical Mission Institute
(3 Health Services and HIV/A1DS
Salvatocstr. 22; D-97074 Wurzburg. Germany
Tel.: +449-931-8048S0. Fax.:+449-931 -80485-25
e mail: mi.heaJth@mail.uni-wuer7burg.de
2S. September 2000
Extract of the book
„Catholic Ethicists on HIV/AIDS Prevention"
edited by Rev. Fr. James F. Keenan; (ISBN 0 8264 1230 0)
The fundamental insight that lead to this book was recognising HIV/AIDS as a social problem. A
coalition of authors has worked intensively to address the problematic, that certain moral positions
adopted by Church personnel arc at odds with some relatively effective HIV prevention measures,
favoured by Catholic health workers involved in the pandemic. The intention of the book is to brmg
evidence that common Catholic moral tradition can help to constructively mediate the apparent clashes
of values.
In the first part of the book, 26 cases from around the world ;ue presented, highlighting the complexity
of HIV prevention and illustrating the importance and relevance of local issues and concerns. On the
other hand, the ability of the Catholic moral tlieological tradition is demonstrated to address HIV
prevention.
Recognising the actual status and trends of the HIV/AIDS pandemic, makes it obvious, that addressing
effective HIV prevention is not simply finding good arguments for prevention, but more important y
addressing the social problems that inhibit HIV prevention measures. As main social problems have to
be mentioned, that:
a. women do not have adequate power in the face HIV/AIDS,
b. religious scrupulosity, irnmHc anxiety and unjustified traditions inhibit effective prevention
work,
.
...
.
c. the integrity of religious traditions needs to be respected,
even
after
20
years
of
pandemic
spread
of
HIV,
homophobia
remains
virulent
and
vicious,
and
d.
e.
there is a profound difficulty in protecting children, in particular in relation to real issues of
teenage sexual contact and drug use.
In the second part of
of the
the book,
book, moral
moral theologians
theologians from
trom all
an over
over the
me world
wmm try
u, to describe the
...
progressive development of the moral tradition in the face of the challenges posed by H1V/A1DS.
Tradtion in Moral Theology
, , .
...
Marciano Vidal (C.Ss.R.) analyses the meaning of tradition in the field of moral theology and is
concerned with developing criteria that govern progress within the Christian moral tradition He refers
to three documents of Church teachings: the Constitution Dei Verbum from Vatican Counsil II (1965),
and John Paul Il’s encyclicals ‘ Veritatis Splendor’ (1993) and 'Centesimus Annus’ (1991).
Bankers: Postgirokonto Numberg (BLZ 760 100 85) Nr. 13898-853
Dresdner Bank AG. Wurzburg (BL2 790 800 52) Nr. 30 11 574 - Uga eG. Wurzburg (BLZ 750 903 00) Nr. 300 6565
C:\Eigene Da’eicn'l)ATA\F.ngti$h\Summary F.thicists.doc
A
He distinguishes between “apostolic” or constitutive tradition and post-apostolic or “Oiurch” tradition
(continuing tradition). The apostolic tradition comprises everything that serves to make people of God
live their lives in holiness and to increase their faith. The moral content of traditton lacks a particular
organ of verification. The Church, in her doctrine, life and worship perpetuates and transmits to every
generation all that She herself is, all that She believes.
The tradition that comes from the Apostles makes progress in the Church, with the help of the Holy
Spirit. The Constitution Dei Verbum describes the dynamic understanding of tradition as a living
tradition of the Church. In the field of moral theology, many advances have been achieved in the
history of the Church. Examples of the most outstanding ones in the last decades are the follow ing.
Advances in Social Ethics
'
• Strengthening of the rights for religious freedom and freedom ot conscience (V atn an 11).
•. The
The moral
moral reaooraisal
reappraisal of
of war,
war, which
which shifted
shifted from
from the
thejust
just war theory to finally the point ot saj mg
no to war.
• The formulation of solidarity as a new virtue and a new principle of social lite.
• The acceptance of ethical, juridical category human rights.
• The preferential option for the poor which manifests the universality of the Churches being and
mission.
Advances in personal ethics
.
r
• There is a holistic comprehension of human being as persons, in particular expressed m nine mm
•
et $Pes-
r
.
•
l
The value of human life has gained depth, especially in he morality of abortion, euthanasia,
•
capital punishment and so forth.
The understanding of the corporal dimension of the human condition has moved beyond itie
staturing biologists’ consideration to distinctive personal comprehension.
Human sexuality is placed today within the framework of an integral vision of person.
•
•
- Advances and fundamental ethics
...
• r
• The universal call to holiness implies that there is no longer a morality of sins, but the pursuit ot
the exalted vocation of the faithful in Christ (Lumen Gentium).
• The limits of the morality “of acts” have been overcome by accepting the complimentary
.
category of fundamental choice.
.
me sin of structures or structural sin is an advance in the formulation of objective and subjective
group culpabilities.
Vatican II formulated principal factors of moral progress. Elements which have to be considered to
achieve progress are the following:
• Continued analysis, to reach a more profound understanding of the Ministry of Chust.
• Ongoing interpretation of die “the signs of the times in the light of tire gospel .
. Considering the rich and diverse human experience, in particular in respect to experience ot the
past ages, from progress of the sciences and from the riches hidden in various cultures.
Moral Theology facing HIV/AIDS
f
Kevin Kelly describes the challenges for moral theology facing the new millennium in a lime ot
AIDS. To help that the Church, the body of Christ, lives positively with AIDS, moral theologians
need to have the courage and confidence to formulate and teach a positive and attractive prison
centred sexual ethics, which is both truly human and truly Christian.
Its aim should be to help humans grow as loving and loved persons, whose loving is truly lite giving
in the fullest sense. It must also be about enabling to find security in relationships of personal
integrity, mutual trust and faithful commitment. There arc two marks of the true Church in limes ot
AIDS:
■ 2 -
1
It should be a Church, which in its life and teaching offers a credible witness of its belief in
'
the full and equal dignity of women, and which repudiates as conlrary to t e gospe
of thinking or acting which implies that women are in any way of inferior status
men.
f'ritirnl qelf-cxamination must be on the agenda of the Church.
It should be a Church which uses the full power of its authority and its influence to change
md eradicate the basic causes of poverty in our world, especial the many factors which o
q,. „ nomimied existence to human agency and which constitute global structural injustice
>r ! • orldwidc sc:dc.
-3 -
ISSN 0017-908X
'
3WS
I
.-ff
!;. •< V'i '-I I
I
Mm.'PaCIFIC EDir/ON
Issue 47
AprilJune
2000
RELIGION AND HIV/AIDS
,x
..
..
■
/
ft
l.t-l- h ;,
Ilfcl
igv iV: Jo A V■ i.
I
i
,<
-
ri
. - II*
> -
:■
IN THIS ISSUE
v.' -r:
4 Buddhist monks
'
respond to HIV/AIDS
4.
■
■
v •
■
•
i O.
____________ __ I
6 Between two paradigms
;■ V “
'i-
F-
7 Religious leaders on
r),„
HIV/AIDS
on, ,he 12th century Bayon temple in C.vnhodm she
■j
eligion has always been part of social life in
I—/I Asia and the Pacific
The region is the
1 _ VI birthplace of such world religions as Hinduism
and Buddhism as well as many other smaller but
significant religions, from Sikhism to Shinto.
3‘
PuM»h»dby
welcoming religions from outside. Today.Asia includes
the largest Islamic countries in the world — Indonesia,
Besides Islam. Christianity
has also flourished in many countries in the region, to
HAIN
name a few. the Philippines. South Korea and the Pacific
island nations
For many Asians and Pacific islanders, religions are
HMkh Artrwi Mf.vw»t>on
N.Hwort< PHMJPPINES
not just a matter of paying homage to the supernatural.
They provide important ethical guidelines for living, for
interpreting natural events including disasters and
healthlink
wowurano*
in a time of rapid social change, with religions not just
surviving but thriving amid modernisation. In fact, in sever .u
countries in the region, religious fundamentalists - Hindu.
Islamic, Christian - have a growing number of followers,
offering a "return to traditions" as the solution to the
At the
same time, the region has often been tolerant,
Bangladesh and Pakistan
huth
uo„„„,
misfortune, and for coping with life’s milestones, from birth
problems of modernisation.
HIV/AIDS poses new challenges to religions
Because its main mode of transmission is sexual. HIV/
AIDS intensifies the tensions that are present around
sexuality. Many religions have had ambivalent attitudes
toward sexuality. Religions have always been important
forms of social control.especially in the area of sexuality
But many religions, especially in the past, also respected
and even celebr ated the powerful forces that come with
sexuality, whether for reproduction or for eroticism.
The ambivalence continues today, and often creates
problems for HIV/AIDS prevention and care. The
epidemic is interpreted by some .people as divine
through illness to death. The;
•/
•
•
•U
■
punishment for sexual transgressions, from premarital sex to
homosexuality. The stigma posed by religion can be powerful.
Governments and NGOs often avoid working with or supporting
groups such as homosexuals or sex workers because they are seen
as sinners who deserve to become infected. Some may even think
of AIDS as a way of cleansing society of such "undesirables”.
Even in countries where there are HIV prevention programmes to
reach such sectors, the targets may themselves be socially inaccessible.
Internalising what religions have said about their "sinful" behaviour, they
remain marginalised, unreached by information and education campaigns.
Religious stigma works most strongly against those who are
infected with HIV, who may be left to fend for themselves. Again,
governments may be reluctant to respond to the needs of people
with HIV because they are seen as sinners. Religious prejudices,
mixed with misconceptions about HIV/AIDS, become a dangerous
and volatile mixture that sends many people to their deaths.
Fortunately, there has been ferment, too, among religious
institutions, as people begin to question biases and prejudices. The
responses have varied. In Thailand, as we see in an article by Noemi
Leis, Buddhist monks are now at the frontlines providing care and
support for people living with HIV, particularly those who are very ill
and who are dying. Christian missionaries and lay workers are doing
similar work in many parts of Asia, again mainly providing institutional
care for the sick and dying. This includes many Catholic workers who
may be reluctant to promote condoms as part of preventive education,
but who are at least willing to minister to the needs of patients.
There are, too. religious thinkers who are tackling the very
doctrinal bases for behaviour. The article in this issue by Masdar
Mas’udi presents, in simple language, the rationale for a more secular
approach in Islam toward the HIV/AIDS epidemic. He explains, for
example, that condom use upholds Islam’s premiere right, the right
to life.
Theologians have tried to tackle other ethical dilemmas brought
about by the threat of HIV/AIDS. For example, some people may
object to needle exchange programmes,
where drug dependants are given new clean
needles. The objections come about because
the programmes are seen as tacit acceptance
of the use of drugs, but religious ethicists will
say that the needle exchange programmes
constitute a lesser evil because it saves lives.
Other religious thinkers, notably Muslim
and Christian, have contributed to the fight
against HIV/AIDS by questioning the role of
religious doctrines in reinforcing gender
inequality, and the way this inequality
contributes to women’s vulnerability to HIV.
Religious norms that force women to be
passive may become a death sentence since
they are then unable to protect themselves,
even if they know their husbands or partners
may have HIV.
The inclusion of religious groups in HIV/AIDS work can produce
many benefits, some of which are explained below:
First, many religious institutions have formidable resources that
can be tapped for HIV work. These religious institutions have their
AIDS ACTION Issue 47 April-June 2000
B
I ■'
own schools, hospitals, clinics and orphanages. While some of these
institutions may be reluctant to discuss sexuality issues, or to promote
condors, they can at least be mobilised to provide other services,
especially for care and support
Second, religion plays such an integral role in people’s lives that
an HIV/AIDS prevention programme cannot be effective unless it
deals with people's religious beliefs and practices.
For example,
government and NGOs need to look at how religious beliefs shape
the relationships between men and women. If women see the risk
Major Religions of the World
of HIV/AIDS as unavoidable, as part of karma, then educational
programmes will not be very effective Religous beliefs and practices
■ also play vital roles in the care and support of people with HIV, It is
Primal Indigenous
important to emphasise the suppportive aspects of religion.
4%—<
working on HIV/AIDS can be mutually beneficial.
Religions offer
Chinese Traditional
programmes that only distribute condoms without encouraging
I
4%----- \
ethical frameworks to discuss many issues that have to be tackled in
HIV/AIDS programmes. Some religious workers rightly object to
Buddhism
4% /
^11
people to discuss what is meant by "correct use”. "Correct is not
just a matter of technical skills, but must also be based on notions of
a mutual respect, and of sharing of responsibilities.
Conversely, people working in public health can bring up very
practical case studies and challenges for religious leaders and thinkers
to tackle What does one do. for example, if a husband is infected
and the wife is still free of HIV? Would they be asked to abstain
Others
- 3%
Third, dialogues between religious institutions and groups
■
kk 11
Christianity
33%
Non
religious
16%
from sex? Or would they be encouraged to use condoms, an option
still not allowed among Roman Catholics?
Sometimes, the implementation of HIV prevention programmes
raises ethical issues that need dialogues. What happens, for example,
I
when a Catholic physician goes around claiming that condoms do
not prevent HIV/AIDS’
Would that not be violating religious
injunctions on speaking thr truth, and on preserving life?
Hinduism
16%
Islam
18%
Dialogues open pen|T ’ minds When religious workers listen
to NGOs and govci nment .-/or kers doing HIV prevention, they begin
to see the potential impact of HIV/AIDS on society,and the need for
Source: http://www.adherents.com
such measures as sex education. Likewise, religious workers are
needed to remind medical people - often jaded by their routines -
to respect human dignity and human rights.
Often, there is a fear that such dialogues will lead to
compromises when in fact they can lead to new richer partnerships.
— Michael L Ton. HAIN
gs O U L
t \Religion can influence a woman's reproductive
health, whether positively or adversely. As the
■
Women's Feature Services (WFS) puts it 'Religion
I JfeA i
is an experience so personal, yet so political, that
Itends to affect many aspects of womens lives,
including reproductive health."
U
j r
To highlight the role of religion and to raise related
;1
r-
issues, a senes of inter-faith discussions on women,
religion and reproductive health are currently
|
being held in the Philippines.Jhe multi-media programme.
aptly called ’Body and Soul'.' was developed by the WFS.
The discussions present pecspectives from the Catholic.'
Protestant and Islam religions,’which are the predominant
religions in the Philippines. Four multi-media discussion
forums have been held, and the papers presented at each
forum have been compiled and published into booklets. The
discussions have focused on the following themes:
Frameworks on Religion and Reproductive Health
Condoms and Religion
Adolescent Sexuality
Population
(Please see page 8 for contact details of WFS)
AIDS ACTION l«ue 47 April-June 2000
Buddhist Monks:
RESPONDINGTO HIV/AIDS
The Buddhist monks have become a very important stakeholder in the fight against HIV/AIDS and are now
recognised as a strong partner in HIV/AIDS work especially through their spiritual guidance.
r
en years ago. Mae Chan hospital in Chiang Rai. Thailand
first encountered cases of HIV. It was at this time that the
— HIV/AIDS epidemic was rapidly spreading in Thailand,
particularly in the northern area which shares borders with Cambodia
I Monks and health workers
planning future HIV/AIDS
activities
and Laos
The hospital staff, however, found it difficult to talk about HIV/
AIDS with the patients Likewise, persons with HIV/AIDS (PHAs)
who were admitted to the hospital did not discuss their thoughts
and feelings with the hospital staff. Instead, the patients were going
to the Buddhist monks for counselling and spiritual guidance.
The health workers at the hospital then realised the monks
played an important role in people’s lives, and decided to explore
ways they could work with the monks. Although the monks were
hesitant when HIV/AIDS was first discussed, they became more open
and receptive to the idea as the number of HIV cases increased, and
their friends and family members became infected Wanting to know
more about a disease which was fast becoming a problem for their
communities,the monks then approached the hospital staff Gradually,
the monks and health workers surted to work together. Since then,
the Mae Chan District Hosp.tal and the Buddhist monks have worked
together for the prevention of HIV/AIDS while providing care and
support for those who are already infected.
NDBLeis/HAIN
WORKINGTOGETHER
Today, Mae Chan hospital has a meditation room where patienu
can read, listen to tapes of Buddhist teachings, meditate or have a oneon-one counstli.ng session with monks. If the patient cannot walk, the
monk stays at the bedside. An audiocassette tape of Buddhist teachings
is aired on the hospital’s sound system so that all the patients can listen.
‘I
In addition to their work in the hospital setting, the Buddhist monks
also provide community support. The temples have become a venue
for several activities for PHAs and their relatives. They do meditations,
I
yoga, exercises, herbal sauna, food preparation and even income
generating projects such as making herbal medicines The monks conduct
home visits as well to talk to those who are infected and affected
Several community therapy centres have been established in
A Buddhist temple I
in Chiang Rai, Thailand ,
Chiang Rai to provide a venue for community interaction Community
members who are not HIV positive go to the centre and prov.de an
informal social support system for the PHAs in the community The
monks regularly visit the community therapy centre to conduct
information campaigns and to provide care and support services.
The monks emphasise meditating before doing activities such
as counselling or treatment Health workers. PHAs. and their families
AIDS ACTION Issue 47 April June 2000
lre ^cond^ng Iducationa! activities, the monks use Buddhist
THE BUDDHIST
AIDS PROJECT
teachings on moral conducts for human behaviour. There are five
moral conducts in Buddhism:
Do not destroy life
© Do not take what is not given
© Abstain from sexual misconduct
Abstain from falsehood
Abstain from intoxicants
The monks do not prohibit condom use. However, they leave
With its goal of linking together Buddhist communities in
different countries, the Buddhist AIDS Project (BAP)
maximises the use of information technology to reach a
wide audience.
r
its discussion to lay educators in the hospital.
Aside from social, spiritual, and emotional support, monks also
provide PHAs their basic needs such as food, clothing, soap, and others.
The monks conduct their own fundraising activities and are not
dependent on the hospital for funding. The Buddhist community has
In trie past, many of the information resources on HIV/
AIDS and Buddhism have not been easy to find. BAP is
working to change that situation. Through its website,
BAP provides easy access to information resources.
traditionally supported the monks, who walk through the streets in
the morning carrying bowls where people can put their donations.
There are also Buddhist festivals when people go to the temples
to bring gifts for the monks.The gifts are usually money, food, clothes,
The project aims to provide free information and referral on.
current HIV/AIDS information, with links to local,
national and international resources
_ Buddhist teachings, practice centres and events
©
© complementary alternative medicine services
and other items.These gifts are then shared with their community.
It is interesting to note that monks have also learned to write
to international agencies for funding, and they have been quite
The website also contains the BAP Library of Articles, which
is a list of information materials on HIV/AIDS. Buddhism,
spirituality, medicine, research findings, conference reports
and announcements, among others.
I
Moreover, the BAP website serves as a virtual gathering
place where many people have made themselves available
for those seeking life enhancing practices that can
strengthen the response to changing physical, rnental. and
successful in generating funds.
Every month, the health workers from the hospital meet with
monks to provide them updates on HIV/AIDS and give information
materials. During these meetings they also talk about future plans
and fund raising activities.
|
spiritual challenges.
BAP serves persons living with HIV/AIDS, including family,
friends, caregivers, as well as people who are HIV negative.
The project provides information on HIV/AIDS and
|
f
BAP is a non-profit project of the Buddhist Peace
Fellowship. Established in 1987, it is now based in San
Francisco. USA. BAP is run by about 30 volunteer
physicians, body workers, counsellors, mediation
instructors and others BAP also welcomes interested
volunteers who are willing to share their time and skills.
Contact: Steve Peskind
Coodinator, BucMNst AIDS Project
Tel: (415) 522-7473
Iaffingeyes6yahoo.com
budcffifctapebudcffi^sprojed.org
httpyA^.buddhlstaidsprojed
Both the hospital worker* and the monks agree that their efforts
complement each other, and that they should go on working together
In providing HIV/AIDS education as well as care and support services.
The participation of PHAs as well as the non-positive community
is also important.
The community therapy centre provides not only social support
but also lessens the impact of stigma. The PHAs have become more
visible in the community without experiencing discrimination from
other community members. Disclosure for PHAs about their HIV-
alternative health care to its (lientcle.
Wlule focusing on the San I rancisco Bay Area
worldwide information and referral services, responding
to requests through e-mail and phone. Recently, BAP has
assisted community service projects in Thailand and
Cambodia. They also offer study and support groups on
basic Buddhist leachings and practice.
LESSONS LEARNED
?
status is thus not a very sensitive issue.
The Buddhist monks have become a very imporunt stakeholder
|
|
!
|
in the fight against HIV/AIDS and are now recognised as a strong
partner in HIV/AIDS work especially through their spiritual guidance.
Explaining the Buddhist response to HIV/AIDS, Supakit, the head
monk in Mac Chan district observes, “Imagine that HIV/AIDS is a
|
|
I
I
1
glass, and you break the glass so that there are many small pieces.
Each of us can pick up a piece. This is easy to do because it is only a
small piece of glass that we have to pick up.We must all work together
to pick up the little pieces so that we will solve the problem1’.
— Noemi D. Bayoneto-Leis, HAIN
Acknowledgments: The author would like to acknowledge the assistance
provided by Ms. leap Pinitsuwon and Dr. Supalert Nedsuwan of Mae
Chan Hospital and Monks Supakit, Sommai, Niwit, Supat Monahir, Pairov,
Muangvisan from Temple Muang Klang.
AIDS ACTION Iwue 47 April-June 2000
H1V/AIDS:
BETWEEN TWO PARADIGMS
N
publication, debate and controversy as HIV/AIDS. Ther$ are
Is it not those who are ill who need, even more, God’s love*
On the argument that HIV/AIDS is caused by sin, secularists
many reasons for this, including HIV/AIDS being incurable
point out that transmission can also occur within the halal (lawful)
o epidemic in the world today attracts as much attention,
and deadly. Another factor which contributes to more public attention
sexual relationship between a husband and wife
to HIV/AIDS is that its main method of transmission is sexual. This
transmission also occurs through blood transfusions and from a
has brought about heated debate and controversy between two
mother to child.
Secularists point out that according to Islamic teaching, there are
paradigms: the religious and secular paradigms. The religious paradigm
claims to be rooted in the sacred texts while the secular paradigm is
the
five human rights: the right to life, the right to believe, the right to
have knowledge, the right to have property and the right to have clan
identity (nasab). Of these
the
five rights, the right to life
paradigm,
is the most important For
rooted in the realities of the world.
Within
of
framework
religious
then,
particularly the more
the
conservative
condom use upholds this
ones,
secularists
premier r ight to life
human beings have no
other way to differentiate
In the context of a
the good (oMioson) from
married couple where one
the evil (al-qabih), except
of them has been infected
through divine revelation.
with HIV, can one allow
Using this perspective,
sexual relations to occur
advocates of the religious
without any protection?
paradigm vieXv the HIV/
Does that not mean we
AIDS epidemic as a
are
blessing in disguise. This
danger,
putting
them
with
in
fatal
looks at HIV/AIDS as a
consequences? Or must
curse and punishment
couples with one infected
from God for humanity's
with HIV be separated
disobedience. Using this
f iever *
Wu have seen many
line of argument, religious
<
conservatives condemn
J
Moreover. HIV
/ //-v
become mfc-vud with I
.
.1 wo:m i.
Would it not Lc
• r.g
the use of condoms because this is seen as justifying illicit sexual relations,
in brothels v.1
i.e., disobedience to God. Some religious conservatives even go to the
to offer the use of condoms to protect themselves, their client, and
extent of saying there should be no room for compassion for those
their family? We understand that zino (illicit sexual relations) is a
ji ,il
According to
religious sin, particularly for those already married But is not uno
conservatives, the only way to prevent HIV/AIDS is to return to the
without protection (i.e., without the use condoms) an even greater
demands of religion and faith.
sin because it allows a deadly virus to be transmltted,
affected by the virus because they are sinners.
Those advocating a secular paradigm say that "good" is defined
These critical questions are difficult to answer by the ulama holding
as something useful for humanity and "truth" is something that can
the very formalistic and conservative religious paradigm A moral and
be proven empirically. This saying explicitly recognises the necessity
ethical perspective concept built on the authority of doctrine without
of looking at the material bases- of one's faith. If so, the religious
people should not look at the human life only from the formal religious
being based on empirical reality tends to become empty words
On the other hand, modern humanity must also be aware of
perspective, but from the reality of material life. As the Prophet
the dangers of a morality without a transcendental dimension because
Muahammad says, "Kaada af-faqru on yakuna kufran: poverty can bring
there is the risk of losing one’s orientation An exchange of views,
about somebody to disbelieve."
where each side is open to the insights of the other, is clearly needed
Responding to conservatives, secularists say that no one can
if we are to work out a program of understanding and action
positively prove that HIV/AIDS is a curse sent by God to punish
— Alasdor F Mai'udi
human beings for disobeying God’s will. Secularists ask how one
Director of The Indonesian Society for Paantren and Community
can justify isolation or "excommunication" of those in great suffering.
Development, Jakarta. Indonesia -0-
AIDS ACTION Issue 47 April-June 2000
Rel ig ious Leaders
Speak Out on HIV/AIDS
I
"God loves you all, without
the magnitude of AIDS epidemic
"To Tibetan physicians, AIDS is
distinction, without limit. He loves those
problem in the ASEAN region is
really something new, and the immediate
cause is negative: sexual liberty... such a
of you who are elderly, who feel the
increasing signiju antly Hie increase has
major illness or major negative event also
burden of the years. He loves^ those of
to be controlled in time, otherwise,
you who are sick, those who arc suffering
has a karmic cause, no doubt. But I think
religious, social and economic
from AIDS. He loves the relatives and
development in the region will he hindered
AIDS also has a positive aspect. It has
friends of the sick and those who care for
and disparities within and between
helped to promote some kind of self
them. He loves us all with an
ASEAN Member Countries will increase
discipline. "
unconditional and everlasting love."
accordingly,
every individual has the right to
— The Dalai Lama, 1994
— Pope John Paul II, California
have (in appropriate and right
September 1997
information on HIV/AIDS Without
having the information nobody will be
"Perhaps the AIDS crisis is God's
able to prevent HIV infection,
way of challenging us to care for one
"For us, an encounter with people
... all Muslim Ieaders in all ASEAN i another, to support the dying and to
infected
with HIV/AJDS should be a
Member Count,:\.^
to be properly I appreciate the gift of life. AIDS need not
moment
of
grace - and opportunity for
trained to use flic IEC instruments and
be merely a crisis: it could also be a God
us
to
be
Christ's
compassionate presence
methods. Die well-trained Muslim leaders
given opportunityfor moral and spiritual
to
them
as
well
as to experience His
will then play their important role in
growth, a time to review our assumption
presence in them."
HIV1 AIDS campaign in their respective
about sin and morality. The modern
(ommunity
epidemic of AIDS calls for a pastoral
response."
— Bishops'Conference
— The Jakarta Declaration of
Islamic Religious Leaders
December 1998
'I
of the Philippines, 1993
— Bishops of Southern Africa
June 1990
Sisters in Islam J
-ee af'-hCape
Located in New
Wales, Australia,
the Tree of I lope is a centre for HIV
positive women and men, and their
partners, family, friends, and care-givers.
The Centre offers Personal Care composed of emotional, spiritual and
social support. Upon request, the
Catholic nuns who operate the Centre
visit persons with HIV/AIDS (PHAs) and
their loved ones at home or in the
hospital. The Centre is open from
Mondays to Fridays during the daytime,
and the answering machine is left on
during the hours that the Centre is
unattended.
Sisters in Islam (SIS)-is a group of
professional Muslim women committed
to promoting the rights of women within
the religious framework. To attain its
objectives, SIS embarks on activities in
four programme areas:
@ Research and interpretation of
textual sources of Islam
<§> Advocacy for policy and lawir ’
c
rerorm
.
v•
© Awareness raising and public
education
..v: ,
© Strategic planning and policy
formulation' i'';i
|
|
■a
r- - .
’
-V*
(Please see page 8 for contact details of SIS)
AIDS ACTION Issue 47 April-June 2000
*
i
•
action'
AIDS and Muslim Communities: Opening
Up by S Alt. Summary of an international meeting
in Karachi to explore the relationship of Muslim
religious and political concepts with HIV
transmission, medical care, and human rights. AIDS/
STD Health Promotion Exchange 1996(2): 13-6.
Available from HAIN.
AIDS and the Muslim Communities—A
Personal Vlew/AIDS and the Muslim
Communities—Challenging the Myths.
Leaflets in English. Gu|rati, Urdu. Arabic. Farsi.
Gengall and Turkish available from The Naz
Project. Palinswick House, 241 King Sc. London
W6 9LP, UK.
Body & Soul: a Multimedia Discussion on
Women, Religion & Reproductive Health,
2000. A collection of papers presented in several
interfaith dialogues related to reproductive
health. Four booklets are available on diferent
themes, namely: Frameworks on Religion and
Reproductive Health; Adolescent Sexuality;
Population; and Condoms and Religion. For
orders, write toWomen’s Feature Service (WFS)
Philippines, 313-E Katipunan Ave., Quezon City.
-^Handle with Care: a Handbook for Care
Teams Serving People with AIDS by RH
Sunderland and EE Shelp. A step-by-step guide
for congregations that wish to organise care teams
to serve people with HIV/AIDS. Contact
Foundation for Interfaith Research and Ministry.
PO Box 205528. Houston. Texas. USA
AIDS Action is published quarterly in seven
regional editions in English. French, Portuguese
and Spanish II has a worldwide circulation of
179,000
The original edition of AIDS Ai lion is produced
and distributed by Healthlink in London
Islam, Reproductive Health and Women’s
Rights. Zainah Anwar and Rashidah Abdullah
(editors). 2000. A collection of papers presented
at a recent conference on Islam and reproductive
health.
The papers were prepared by
theologians, academicians and NGO workers
They discuss Islamic teachings —drawing from
the Quran and hadith — and its relationship to
reproductive health and rights, on issues ranging
from HIV prevention to gender relations
Available for US$20 (RM40) plus postage cost
which is 25% of the total order for surface mail
and 100% of total order for airmail Write to
SIS Forum (Malaysia) Berhad. Sisters in Islam. JKR
No. 851, Jalan Dewan Bahasa. 50640 Kuala
Lumpur. Malaysia.Tel: (603) 242 6121/24. 3705.
Fax: (603) 248 3601. Write to sis@sisfora po my
• AIDb At tii'ii .A-i.l I’iI.i/u fdihoH >(*//
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Editor
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Philippines. wfs@pacific.net.ph
Catholic Ethidsts on HIV/AIDS Prevention,
2000. James Keenan (editor). A collection of
essays and case studies discussing HIV/AIDS
prevention from a Catholic perspective, drawing
on theology, philosophy and ethics. It includes a
good selection of 26 case studies, based on reallife situations from different countries - developed
and developing — with a discussion of options.
Available for US$24.95 (Paperback) from
Continuum International Publishing Group. Inc.,
370 Lexington Ave., New York. NY 10017. USA;
or £15.99 from Continuum International
Publishing Group Ltd., Wellington House. 125
Strand. London WC2R0BB; Or visit their website:
http://www.continuum-books.com
The Church Responds to HIV/AIDS : a
Caritas Internationalis Dossier, 1996. A
selection of statements on HIV/AIDS by Catholic
Church leaders such as Pope John Paul II. bishops'
conferences and other church groups. The
booklet presents the stand of the Church based
on its teachings and as shown by pronouncements
of Church officials. Available for £i.5O from
CAFOD, Romero Close. Stockwell Road. London
SW9 9TY.UK. ISBN I 871 549 639
Publishing partners
x/The Jakarta Declaration is the result of the
First HIV/AIDS ASEAN Regional Workshop of
Islamic Religious Leaders held November 30December 3. 1998. The Declaration sets forth
the rationale for the involvement of Muslims in
the regional response to HIV/AIDS It also
includes a Plan of Action which presents
objectives, activities, and recommendations
identified at the workshop Posted on SEA AIDS
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or his article or photograph
Suite I von 2
Tolerant Signals:
The Vatican’s new insights on condoms for
II.I.V. prevention
Jh |(v I > l iilltj ; nd lames I Keenan
Ameiica. Suplcmbci 23,2IIH>
Copyright America Press 2000
Jon D Fuller S J., M.D., is an associate professor of medicine at Boston University School of
Medicine and assistant director of the Adult Clinical AIDS Program at Boston Medical Center,
lames F Keenan, S J., is a professor of moral theology at Weston Jesuit School of Theology in
Cambridge, Mass., and recently edited Catholic Ethicists on HIV/AIDS Prevention (Continuum,
2000) with the assistance of Father Fuller, Lisa Sowle Cahill and Kevin Kelly.
Monsignor Jacques Suaudeau of the Pontifical Council for the Family recently published
‘ Prophylactics or Family Values? Stopping the Spread of H1V/A1DS” in the weekly edition of
L'Osservatore Romano (4/19). Here we find important signals of what many have suspected all
along that while individual bishops and archbishops have occasionally repudiated local H.l.V.
prevention programs that include the distribution of prophylactics (more commonly referred to as
condoms), the Roman curia is more tolerant on the matter.
Monsignor Suaudeau reports that the Catholic Church has been accused of “lacking a sense of reality
and of being irresponsible about the H.l.V.-AIDS epidemic in Africa because of its position
regarding the use of prophylactics to prevent sexual contamination.” In response, Suaudeau
introduces a distinction between prevention (attacking a problem at its roots) and containment
(interventions to lessen the impact of a problem). Against malaria, for instance, containment efforts
have been of limited success because truly preventive efforts (such as eliminating all mosquito
larvae) are so difficult. In contrast, in the case of typhoid fever, prevention was achieved because
public health officials aimed to correct the mistaken attitude that care did not need to be taken about
sources of drinking waler.
With that distinction in mind, Suaudeau advances his thesis regarding prevention: “Family values
guarantee true human victory. Wherever there is true education in the values of the family, of
fidelity of marital chastity, the true meaning of the mutual gift of self...man will achieve a
victory' even over this terrible phenomenon.” He adds: “If people really want to prevent AIDS, they
must be convinced to change their sexual behavior, which is the principal cause of the infection s
spread. Until a real effort is made in this regard, no true prevention will be achieved. The
prophylactic is one of the ways to ‘contain’ the sexual transmission of H.l.V.-AIDS, that is, to limit
its transmission.”
After citing apparently confiicting data about the reliability of prophylactics, the author backs away
from the issue and claims, “In any case, the church’s position on the prevention of H.l.V.-AIDS is
not at this technical health care level.” Instead, he argues, the church is concerned about the root of
the problem, that is, respect for human sexuality. Here he also mentions the “condition of women as
well as poverty, political instability, unemployment, the growth of prostitution, the condition of
refugees civil wars and urban crowding of the poor as critical factors that fuel the transmission of
http://www.americaprcss.org/articles/fuller-keenan.htm
14.09.00
Seite 2 von 2
H.I.V. in the developing world.
After a strong endorsement of sexual abstinence, the author applies his distinction to tv. o \ cry
important populations: commercial sex workers in Thailand and the general population of Uganda.
He notes that in Thailand “the use of condoms had particularly good results for these people with
regard to the prevention [we would have thought he would have written “containment | of sexually
transmitted diseases." He adds, “The use of prophylactics in these circumstances is actually a lesser
evil ’ but it cannot be proposed as a model of humanization and development. I ic wmnlcis
therefore, why authorities did not examine why there was growth m the 1 hai prostitution mdustiy in
the first place. He calls attention to more comprehensive approaches in Uganda. While ^cognizing
thaf“sexually active men and women use prophylactics more frequently,'’ the f.a lms he iinds more
important include a delay in the age of first intercourse among both men and women and a decrease
in sexual relations outside of marriage.
Monsignor Suaudeau’s article conveys important insights about Vatican curial thinking on HJ.V.
only that prophylactics alone are inadequate prevention. Fourth, while noting that ur her sluelies
regarding the adequacy of prophylactic usage for H.I.V. prevention are still needed it does no
categorically deny their effectiveness. Fifth, it acknowledges the positive function that prophy actics
have8playedyin two populations critically affected by the H.I.V. epidemic. Sixth, it recognizes the use
of prophylactics as a lesser evil, an important principle used to describe mora ly permissible thoug
regrettable action. Finally, it concludes by recognizing the need for more fundamentally human, life-
enhancing programs to prevent H.I.V. transmission.
While many readers may be surprised by the article’s tolerance, we arc not. Admittedly the Vatican
has intervened otherwise, as in 1988, when the Congregation for the Doctrine of
Fmth raise
Questions about the U.S. Catholic Conference’s pastoral letter The Many Faces of AIDS. A Gospe
Response (1987), and again in 1995, when the same congregation acted against a resource pack on
H I V education published with an imprimatur by the archbishop of St. Andrews and Edinburgh.
However health care workers and moral theologians have encountered an implicit tolerance from the
Roman aS. X they have first asserted church teaching on sexuality and subsequently addressed
the prophylactic issue. For instance, more than 25 moral theologians have published articles claiming
thatwithout undermining church teaching, church leaders do not have to oppose bul may supportc
distribution of prophylactics within an educational program that first underlines church teaching
sexuality. These arguments are made by invoking moral principles like those of lesser evil
“cooperation,” “toleration” and “double effect.” By these arguments, moralists around the world
recognize a theological consensus on the legitimacy of various H.I.V. preventive efforts.
Without known interference, the Vatican has allowed theologians to achieve this consensus. Vatican
curial officials now seem willing publicly to recognize the legitimacy of the theologians argumen s.
Hesitant local ordinaries will in turn, we hope, note Monsignor Suaudeau s tolerant signals and more
easily listen to the prudent counsel of their own health care and pastoral workers and their moral
theologians.
Home
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14.09.00
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■
*3.6.
■
■ Voluntary Counselling
■ and Testing (VCT)
UNAIDS
UMClf • UK* • UMM • UN OCT
UNIKQ • WHQ » WQIttO IANS
» UNAIDS
® Technical update
IS
R
BS
R
ffl
H May 2000
UNAIDS Bost Practice Collection
At a Glance
|
UNAIDS Krst Prdcticc mate ruils
HIV voluntary counselling and testing (VCT) has been shown to
have a role in both HIV prevention and, for people with HIV
infection, as an entry point to care. VCT provides people with an
opportunity to learn and accept their HIV serostatus in a
confidential environment with counselling and referral for ongoing
emotional support and medical care. People who have been tested
seropositive can benefit from earlier appropriate medical care and
The Joint United Nations
Programme on HIV/AIDS (UNAIDS)
interventions to treat and/or prevent HIV-associated illnesses
Pregnant women who are aware of their seropositive status can
prevent transmission to their infants. Knowledge of HIV serostatus
can also help people to make decisions to protect themselves and
their sexual partners from infection. A recent study has indicated
that VCT may be a relatively cost-effective intervention in
in AIDS prevent on. cam and
support A Best Pi at (ice Collection
preventing HIV transmission.
There are several challenges related to the establishment and expansion
of VCT services:
Limited access to VCT. Many of the countries most severely
affected by HIV are also among the poorest countries. Establishing
VCT services Is often not seen as a priority because of cost, lack of
laboratory and medical Infrastructure and lack of trained staff. This
has resulted in VCT being unavailable to most people in highprevalence countries. It is important to document the benefits of VCT
publishes materials on sunjecls of
relevance to HIV infection and
AIDS, the causes and consequences
of tne epidemic, and bust practices
on any one subjec l typically
includes a short publication for
journalists and community leaders
(Point of View); a technical summary
of the issues, challenges and
solutions (Technical Update); case
studies fiom around the world (Best
Pructice Case Studies), a set of
presentation graphics, and a listing
of Key Materials (reports, articles,
books, audiovisuals, etc.) on the
subject I hese documents aie
updated as necessary
in order to promote and expand access to it.
Improving the effectiveness of VCT. Innovative ways can be
developed to reduce the costs of VCT by using cheaper and more
efficient HIV testing methods and strategies. Improving Information,
Education and Communication (IEC) to advocate the benefits of VCT
and raising community awareness may lessen the time required for
pre-test counselling. Integrating VCT Into other health and social
services may also improve access and effectiveness and reduce cost.
Social financing of VCT services has also been shown to be an
effective approach in some settings.
Overcoming barriers to testing. In some countries where VCT
services have been established there has also been a reluctance of
people to attend for testing. This may be because of denial and of
the stigma and discrimination that people who test seropositive may
face, and the lack of perceived benefits of testing. To overcome the
barriers to establishing VCT suivices it is important to demonstrate its
effectiveness and to challenge stigma and discrimination su thai
people are no longer reluctant to be tested. The role of V(. I as a
part of comprehensive health care, with links to and from othe r
essential health care services (such as tuberculosis services and
antenatal care), must be acknowledged The stiucture of VCT
services should be flexible and reflect an understanding of the needb
of the communities they serve. Services should be easily accessible
and closely linked with community organizations that can provide
care and support resources beyond those offered by VC1 services
&
Technical Updates and Pomis ot
View are published in English
French. Russian and Spanish Single
copies of Best Practice materials are
available free from UNAIDS
Information Centres To find tiie
closest one. visit the UNAIDS
website (htlp://www unaids.org).
contact UNAIDS by email
(unaids@unaids org) or telephone
(■*41 22 791 4651). or write to th«;
UNAIDS Infornution Centiu
20 Avenue Apjnu 1211 Geileva 2 /
Switzerland
alone.
Publicizing the benefits of VCT. Until recently, there was a
paucity of data indicating that VCT may be important in changing
sexual behaviour and a cost effective intervention in reducing HIV
Voluntary Counselling anti Testing
(VC I) UNAIDS technical update
English original, May 2000
transmission. However, there are now studies available showing that
VCT is a cost-effective intervention in preventing HIV transmission
and that VCT gives seropositive people earlier access to medical
care, preventive therapies and the opportunity to prevent mother to-
I. UNAIDS
child transmission of HIV.
a
Understanding the needs of specific client groups. VCT services
should be developed to provide services for vulnerable or hard-toreach groups. Community participation and involvement of people
living with HIV is essential if these services are to be acceptable and
II Series
1 . Volnnltiiy woikuib
2. Counselling
3 AIDS serodiugnosis
UNAIDS. Geneva
W<:503 o
relevant.
2
&!■■■■■■■■■■■■
May 2000
I
UNAIDS Technical Update Voluntary Countclhnq and TeMmg <VCD.
an
B
B
B
B
Background
What is VCT?
Voluntary HIV counselling and
testing (VCT) is the process by
which an individual undergoes
counselling enabling him or her to
make an informed choice about
being tested for HIV. This decision
must be entirely the choice of the
individual and he or she must be
assured that the process will be
confidential.
UNAIDS policy statement on
VCT’
VCT has a vital role to play within a
com [wo I tensive range of measures
for HIV/AIDS prevention and
st ipj - m t .Hid should be
ou . ........
I. 11'0 potential benefits
r f ’< in 3 md (('tinselling for the
it’ ‘i. idi ial include improved health
status Through good nutritional
advice and earlier access to care
and treatment/prevention for HIVrelated illness; emotional support;
better ability to cope with HIVrelated anxiety; awareness of safer
options for reproduction and Infant
feeding; and motivation to initiate
or maintain safer sexual and drugrelated behaviours. Other benefits
include safer blood donation.
UNAIDS therefore encourages
countries to establish national
policies along the following lines:
Make good-quality, voluntary
and confidential HIV testing
and counselling available and
accessible
’
T
2
3
Ensure informed consent and
confidentiality in clinical care,
research, the donation of
blood, blood products or
organs, and oilier situations
where an individual's identity
will be linked to his or her HIV
lest results.
Strengthen quality assurance
and safeguards on potential
abuse before licensing
commercial HIV home collection
and home self-tests.
private discussion of sexual
matters and personal worries.
Counselling must be flexible and
focused on the individual client's
r
Encourage community
involvement in sentinel
surveillance and
epidemiological surveys.
■
Discourage mandatory testing.
In some settings HIV counselling is
available without testing. This may
help promote changes in sexual
risk behaviour. In one rural area,
community-based counselling
significantly Increased rates of
condom use among adults.3
a
Elements of VCT HIV counselling
HIV counselling has been defined
as "a confidential dialogue
between a person and a care
provider aimed at enabling the
person to cope with stress and
make personal decisions related
to HIV/AIDS. The counselling
process includes an evaluation of
personal risk of HIV transmission
and facilitation of preventive
behaviour?'2 The objectives of
HIV counselling are the
prevention of HIV transmission
and the emotional support of
those who wish to consider HIV
testing, both to help them make a
decision about whether or not to
be tested, and to provide support
and facilitated decision-making
following testing. With the
consent of the client, counselling
can be extended to spouses and/
or other sexual partners and other
supportive family members or
trusted friends where appropriate.
Counsellors may come from a
variety of backgrounds including
health care workers, social
workers, lay volunteers, people
living with HIV, members of the
community such as a teachers,
village elders, or religious
workers/leaders.
HIV counselling can be carried
out anywhere that provides an
environment that ensures
confidentiality and allows for
specific needs and situation.
Voluntary testing
HIV testing may have far-reaching
implications and consequences for
the person being tested. Although
there are important benefits to
knowing one's HIV status, HIV is.
in many communities, a
stigmatizing condition, and this
can lead to negative outcomes for
some people following testing.
Stigma may actively prevent
people accessing care, gaining
support, and preventing onward
transmission. That is why UNAIDS
stipulates testing should be
voluntary, and VCT should take
place in collaboration with stigmareducing activities.
Confidentiality
Many people are afraid to seek
HIV services because they fear
stigma and discrimination from
their families and community. VCT
services should therefore always
preserve individuals' needs for
confidentiality. Trust between the
counsellor and client enhances
adherence to care, and discussion
of HIV prevention. In
circumstances where people who
test seropositive may face
discrimination, violence and abuse
it Is important that confidentiality
be guaranteed. In some
circumstances the person
UNAIDS. Policy statement on HIV testing and counselling. Geneva, UNAIDS, 1997 (see for full statement).
WHO Counselling for HIV/AIDS. A key to caring. For policy makers, planners and implementers of counselling activities.
Genova, World Health Organiratlon/GPA, 1994.
Moguls f et al. A community-based counselling service as a potential outlet for condom distribution. Abstract WcD834,
9th International Conference of AIDS and STD In Africa. Kampala, Uganda, 1995.
3
Volumnry Coun-.fllinq and TcM«ng (VCT) UNAIDS Technical Update
M'>y ?ooo
I
___________-
ft ■ I
■ Background
s
requesting VCT will ask for a
partner, relative or friend to be
present. This shared
confidentiality is appropriate and
often very beneficial.
Figure 1: Pre-test and Post-test^Counselllng
_________> Development of community awareness <
Decision to attend fo' testing
4-
The counselling process
The VCT process consists of pre
test, post-test and follow-up
counselling. HIV counselling can
be adapted to the needs of the
client/s and can be for individuals,
couples, families and children and
should be adapted to the needs
and capacities of the settings in
which it is to be delivered. The
Risk prevention
Coping strategies
Decision to test
No
test counselling and post-test
counselling). More sessions can
be offered before or after the test,
or during the time the client is
waiting for test results.
Pre-test counselling
HIV counselling should be offered
before taking an HIV test. Ideally
the counsellor prepares the client
for the test by explaining what an
HIV test is, as well as by correcting
myths and misinformation about
Yes
Post-test counselling
HIV-Negative:
News given
Risk reduction reinforced
Discussion about
disclosure of HIV status
HIV-Positive:
News given
Emotional support
Discussion about sharing
Discussion about onward referral
HIV prevention
I
(MTCT).
Counselling as part of VCT Ideally
involves at least two sessions (pre
I
|
The test process
The implications of testing
Risk assessment
content and approach may vary
considerably for men and women
and with various groups, such as
counselling for young people, men
who have sex with men (MSM),
injecting drug users (IDUs) or sex
workers. Content and approaches
may also reflect the context of the
intervention, e.g. counselling
associated with specific
interventions such as tuberculosis
preventive therapy (TBPT) and
interventions to prevent motherto-child transmission of HIV
Establishing good rapport and
showing respect and
understanding will make problem
solving easier in difficult
circumstances. The manner in
which news of HIV serostatus is
given is very important in
facilitating adjustment to news of
HIV infection.
----
Pre-test counselling:
Follow-up counselling and support as required
HIV/AIDS. The counsellor may
also discuss the client's person..1
risk profile, including discussion,
of sexuality, relationships, possible
;.ux and/or druy-i elated behav: u.
that increase risk of infection, ..ml
HIV prevention methods
Thu
counsellor discusses the
implications of knowing one's
serostatus, and ways to cope with
that new information. Some of the
Information about HIV and VC1
can be provided to groups. This
has been used to reduce costs and
can be backed up by providing
written material. It Is important,
however, that everyone requesting
VCT has access to individual
counselling before being tested
People who do not want pre-test
counselling should not be prevented
from taking a voluntary IIIV test (f<x
example people who have had VC I
may request testing but not wish to
have further pre-test counsellinq)
I lowcvci. informed consul.! ficim
u.illy
ii i person Luiiig t< t<■ i . •
i i .1
,i minimum eihic.il n , > ‘
b. loiu an IIIV lust
Post-test counselling
Pusl-lest counselling should always
be offered. The main goal ot this
counselling session is to help
clients understand their test results
and initiate adaptation to their
seropositive or negative status
When the test is seropositive. Ute
counsellor tells the client the result
clearly and sensitively, providing
emotional support and discussing
how he/she will cope During this
4
!!■■■■■■■■■■■■
May 2000
I
U N AI OS Icchnical Upd.Mft Voluntary Counselling andlcstingJWT^
■
■■
;
•'
■. 1F ;-’*.••••
Background
■
session the counsellor must ensure
that the person has immediate
emotional support from a partner,
telative or friend. When the client
is ready, the counsellor may offer
information on referral services
that may help clients accept their
IIIV status and adopt a positive
outlook. Sharing a seropositive
result with a partner or trusted
family member or friend is often
beneficial and some clients may
wish someone to be with them
and participate in the counselling.
Prevention of HIV transmission to
uninfected or untested sexual
partner/s must also be discussed
Sharing one's HIV status with a
sexual partner is important to
enable the use of safer sex
practices, and should be
encouraged. However, it may not
always be possible, especially for
women who face abuse or
abandonment if known to be
seropositive.
Counselling is also important
when the test result Is negative.
While the client Is likely to feel
relief, the counsellor must
emphasize several points.
Counsellors need to discuss
changes in behaviour that can
help the client stay HIV-negative,
such as safer sex practices
including condom use and other
methods of risk reduction. Tlx?
counsellor must also motivate the
client to adopt and sustain new,
safer practices and provide
encouragement for these
behaviour changes. This may
mean referring the client to
ongoing counselling, support
groups or specialized care services.
During the "window period"
(approximately 4-6 weeks
immediately after a person is
infected), antibodies to HIV are not
4
5
6
7
always detectable Thus, a
negative result received during this
time may not mean the client is
definitely uninfected, and the client
should consider taking the test
again in 1 - 3 months.
including medical care, ongoing
emotional support and social
support. People who test
seronegative can have counselling,
guidance and support to help
them remain negative.
Counselling, care, and support
after VCT
Entry point to medical care
VCT services should offer the
opportunity for continued
counselling to people whether they
are seropositive or seronegative.
For seropositive people,
counselling should be available as
an integral part of ongoing care
and support services. Counselling,
care, and support should also be
offered to people who may not be
infected, but whom HIV affects,
such as the family and friends of
those living with HIV*
HIV testing
The diagnosis of HIV has
traditionally been made by
detecting antibodies against HIV.
There has been a rapid evolution
in diagnostic technology since the
first HIV antibody tests became
commercially available in 1985.
Today a wide range of different
HIV antibody tests are available,
including ELISA tests based on
different principles, and many
newer simple and rapid HIV tests.5
Most tests detect antibodies to HIV
in serum or plasma, but tests are
also available that use whole
blood, dried bloodspots, saliva and
urine.6
VCT as an entry point to pre
vention and care
VCT is an important entry-point to
both HIV prevention and HIVrelated care. People who test
seropositive can have early access
to a wide range of services
Health care services may refer
people, particularly those with
symptomatic disease, to VCT, to
aid with further management.
Collaboration and cross-referral
can ensure that people with HIV
receive appropriate medical care,
including home care and
supportive and palliative care.
1 here are benefits of other health
care services, such as tuberculosis
services, working in close
collaboration with VCT services.
People attending VCT can be
screened for clinical TB and treated
appropriately, or offered TBPT if TB
screening is negative, and TB
services can refer people to VCT.
This may be particularly important
In countries where dual infection is
common, with up to 70% of
people with TB also having HIV
infection, and TB being a major
cause of morbidity and mortality in
people with HIV.7 Prevention or
early treatment of TB in people
with HIV can be a cheap and
effective intervention.
Entry point for preventing
mother-to-child transmission
of HIV infection (PMTCT)
interventions
Increasing numbers of countries
are now offering interventions to
PMTCT. VCT is offered within the
antenatal setting or close links
are formed with VCT services. It
is important that women
receiving VCT in this setting have
adequate time to discuss their
WHO. Source Book for HIV/AIDS Counselling Training. Geneva, WHO/GPA, 1994.
WKO. Thti Importfincft of 9lmpl9 and rapid lasts in HIV diagnoiUct: WHO racommendoliont, Weakly Epidemiological Record
73 (42) 321 328, October 1998
-vT
UNAIDS. HIV testing methods: UNAIDS Technical Update. Geneva, UNAIDS, November 1997,
Elliott A or al The impact of HIV on tuberculosis in Zambia: a cross sectional study. British Medical Journal, 1990, 301: 412-415.
5
OCT Coumellinfl and To»ti
(VCD: UNAIDS Technical Update
May 2000
o
W
3
3
■
•
•
si
o
fc-a
Background
®
i ■■
i Ki?
u I
own needs and not Just those
concerned with PMTCT. and that
there are links with services
which can provide ongoing’
support and care for women with
HIV.
When counselling women in the
antenatal setting for PMTCT
interventions, special
consideration should be given to:
w
counselling about prevention
of HIV infection during
pregnancy and breast-feeding
spiritual services, traditional
medical practitioners and support
groups for people living with HIV
counselling on the
advantages and
disadvantages of disclosure,
particularly to her partner
Entry point for social support
involving the partner in
counselling and decision
making
■
counselling about infant
feeding options
Entry point for ongoing
emotional and spiritual care
K
counselling about all
available PMTCT options
■
family planning counselling
■
for seropositive women,
referral for ongoing medical
and emotional support
■
for negative women,
Although the Immediate
emotional needs of people
following VCT may be met by the
counselling service some people
will require longer-term support
and care. Counsellors will need
to be aware of all services
available for people following
testing. These may Include
I ; ' ll A
One of the benefits of VC I is that
it can help people with HIV to
make plans for then future and
the future of their dependants.
HIV counsellors should be
knowledgeable about legal and
social services available to help
people with these decisions.
Material and financial support is
sometimes requested, and
counsellors need to be aware of
any available services, although
these are often limited in
developing countries
Figure 2: VCT as an entry point for pi evention and care
.. '/^•■Actepanoe of and coping
J With serostatus . • i '>'''
---------
I.Panning for the future
roof orphans.dependanu
[^imfly, making will etc.)
Normalization &
dettlgmathation
’ •)
'A'
Promotes and
ifZj facilitates behavKXM cha/ige
(sexual, safe ‘njectingV^/^/
"-----
Prevention
/of mother-to-chrld
h transmission
x
J
^^I^^iv/aids
VCT
i^fivnunity support. IndudW„.y.
\ >people kving with HfV support'*^
*
_ youps^Jj^^
; Access to
and its links
. i gfek
<
famfly planning
to condoms
^^UandfemaK) .
frovision of
»
•. maternity services .
rj^ople living with HfV ' (•X
-------- >
with other
services
'
STI prevention.
and treatment
.
Eady management ;
/.g- of opportunistic
infections
V
to warty medical care ■'
ARV - antiretroviral
Ol - opportunistic Infections
STI - sexually transmitted infections
Ja
, pJevencivo
)
■ihFl«rtfi»r
* RV
**1/s_____ ItL'i—tMrjpy
tL'r
for TB. and other Ols • ' .
6
■■■■■■■■■■■■a
1
May 2000
UNAIDS Technic.il Update Voluntary Counselling and Testing (VCT)
&
&
■
The Challenges
■
■
I imitcd access to VCT
VCT has not been seen as a
priority in HIV care and
prevention programmes in many
developing countries and has
therefore often not been widely
available Reasons for this
include:
complexity of the intervention
the relatively high costs of its
var ious components
the lack of evidence of its
effectiveness in (educing HIV
transmission
the lack of evidence of its cost
effectiveness as measured by
number of cases of HIV
averted
It is sometimes difficult to
measure the impact of
counselling on behaviour change
It is understandable that VCT will
often not have an easily
measurable effect, because of the
complexity of sexual behaviour
and relationships, and factors
which affect these, such as gender
inequalities, and lack of
empowerment of women in many
high prevalence settings. In
countries where resources are
very limited VCT services may,
therefore, not obtain priority in
government planning, and
counselling may not receive the
official approval, resources, and
support it needs to be
implemented effectively
Decision-makers may also
question the benefit of providing
counselling and testing services in
places where clinical care options
are limited.
Improving effectiveness of VCT
Even where VCT is considered
important, its widespread
implementation is often limited by
Q
lack of funding, infrastructure,
trained and designated staff, clear
policies on staffing and service
sustainability. Counsellors often
have other roles within a health
care system - such as nursing or
social work - which reduce the
time available for counselling as a
part of HIV testing. Without
adequate staffing levels and
policies guaranteeing counselling
as a priority, pre-test and post-test
counselling are often not
delivered al all. or are done so
hurriedly that clients are not given
the time and attention they need.
Inadequate preparation of the
settings in which VCT services are
offered may also be a problem.
This may result in insufficient
privacy during counselling
sessions. Inconvenient opening
times or difficult physical access.
Clients may feel intimidated by
reception staff or have fears
regarding the confidentiality of
their test results.
Burnout - emotional exhaustion
that results when a counsellor has
reached his or her limit to deal
with HIV and its related emotional
stress - may result in rapid
turnover of counsellors. This is
especially true in high-prevalence
areas, where the "breaking of
bad news" may occur several
times a day. Effective VCT services
must find ways to ensure ongoing
support and supervision of
counsellors and help them to
cope with burnout and remain
motivated.
contributing factors that must be
addressed if VCT is to have an
important role in HIV prevention
and care:
Stigma HIV is highly stigmatized
in many countries and people
with HIV may experience social
rejection and discrimination.8 In
low-prevalence countries, or
places where HIV is seen as a
problem of marginalized groups,
rejection by families or
communities may be a common
reaction. This fear of rejection or
stigma is a common reason for
declining testing.
Gender inequalities The need
for protection and support of
vulnerable women who test
seropositive must be considered
when developing VCT services. In
Zambia, women said that it was
thought to be shameful to have
HIV and if they were known to be
seropositive. They worried that
they would suffer discrimination.
Studies from Kenya have also
shown that women may be
particularly vulnerable following
VCT and in some cases have lost
their homes and children or have
been beaten or abused by their
husbands/partners if their status
became known.®
Discrimination In some
countries people with HIV are
subject to discrimination at work
or in education. Unless
legislation is in place to prevent
this some people will be reluctant
to undergo VCT.
Publicizing benefits of VCT
Overcoming barriers to VCT
Although VCT is becoming
increasingly available in
developing and middle-income
countries, there is still great
reluctance for many people to be
tested. There are several possible
Even in areas where VCT services
are available, uptake of services is
often poor. A common barrier to
VCT is the lack of perceived
benefit.’0 If VCT is linked with
medical care, and effort is made
K.trim Q , Karim S.. Soldan K , Zondi M. (1995) Reducing the stigma of HIV Infection among South African $ox workers:
irinncnnrmic nntl qnndnr barriers. American Journal of Public Health 85 (11). 1521-5
I' -nt”- rnun M rt al. The right not to know HIV-test results. Lancet, 1994, 345:696-697.
r
■'(••y I? cf al Barriers to HIV counselling and testing (VCT) in Chawama, 1995, Lusaka, Zambia, 9th International
■
nf'i r/i'i <'> AIDS and SI its in Africa, December 1995.
Voluntary Counselling mid Testing (VCT): UNfilDS Tcchmciil Update
Mny 2000
£
■
■
®
& Ha
|
__________ _
«a Si
§
Responses
to Improve medical services for
people with HIV, this will help to
reduce this barrier to testing.
Offering interventions to prevent
MTCT can also be recognized as
a major benefit of VCT.
Expanding access to VCT
Understanding the needs of
specific client groups
e
The HIV epidemic does not affect
all sectors of society equally, or in
the same way within countries or
cities. Some groups are
particularly vulnerable to HIV for
a variety of reasons including
age. profession or specific risk
behaviours. For example in the
former Soviet Union HIV is
largely a problem among IDUs
and the HIV prevalence in the
general population is low. It may
therefore be appropriate to
provide specific resources for VCT
for IDUs rather than provide a
comprehensive service for the
general population. VCT services
which are acceptable to one
group - for example, to men who
purchase the services of
commercial sex workers - may
not be acceptable for other
groups, such as the sex workers
themselves. Rapid assessment
techniques for analysing
potential client needs in a given
area may exist, and are relatively
inexpensive and simple to carry
out. However, there may not be
adequate and locally available
management expertise for
creating effective services in
response to the findings of an
assessment.
For VCT services to be promoted
and developed it is important to
document their usefulness in
Reducing HIV transmission
Improving access to medical
and social care
K
Facilitating MTCT interventions
X»
Improving coping for pcoph;
with HIV
Several studies have demonstr.ik i
that VCT can prevent HIV
transmission among serodiscordant
couples. There have also been
some studies showing significant
behaviour change In individuals
following VCT. A recent multi-site
study conducted in Kenya, United
Republic of Tanzania and Trinidad
has provided data on the role of
VCT in HIV prevention and its costeffectiveness compared with other
HIV prevention interventions.” This
study demonstrated that VCT
significantly reduced sexual risk
behaviour - specifically,
unprotected sex with non-primary
partners, with commercial sex
workers, and among couples who
have been tested and counselled
together. Furthermore VCT did not
increase the occurrence of negative
effects such as stigmatization or
disintegration of relationships. The
study also showed that VCT could
he cost-effective in terms of the cost
per HIV infection averted The cost
per client for VCT was $29 in the
United Republic of Tanzania and
$27 in Kenya, and was more cost■ r''' »ive wh
‘c i to HIV
positive persons, couples, and
women.
There are several examples where
VCT has been shown to help
people access appropriate medical
and social services.12
In industrialized countries VCT
enables people to access
antiretrovirals (ARVs) earlier and
therefore decrease HIV-associated
morbidity. In developing countries
PLHA can have access to TBPT and
targeted health care
If pregnant women are to have
access to interventions to prevent
MTCT it is inifxjd.Hit th.it they know
arid understand ill n HIV status
V( F ost.<x i. Hi J .. iii > MI ( I
Il iL i V .1 illllii . Ii i: bixill >|lij.»/l 1.1 i.i;
acceptable in s.iuh. cuttings 1
However, barriers to VCT set vices in
antenatal clinics exist whereassociated ongoing care and
support are not available for
pregnant women
Reducing the costs of VCT
The cost of HIV testing has been
reduced significantly over the past
decade, as cheaper testing
methods are manufactured.
Simple/rapid testing enables testing
to be carried out without laboratory
facilities and equipment or highly
trained personnel. These factors
could enable HIV testing to be
made more widely available and
can be suitable for rural arecis and
sites outside capital cities.
Innovative appi caches can be
devised to help make the
counselling component of VCT less
labour-intensive. Group education
prior to pre-test counselling can
shorten the length of time required
for one-to-one counselling, and
hence reduce costs. Sometimes
counselling can be c.in a !
trained volunteers or lay people
and this may also reduce costs.
However, if volunteers or lay
counsellors are employed adequate
training, supervision and support
must be ensured, otherwise
counsellors may leave and burnout
11 Sweat ML el al. Cost-effectivcnoss of voluntary HIV-1 counselling and testing in reducing sexual transmission of HIV in
Nairobi, Kenya and Dar Es Salaam, Tanzania: the voluntary HIV-1 counselling and testing efficacy study Lancet, 2000, July
12 WHO. TASO Uganda, the inside story: Participatory evaluation of HIV/AIDS counselling, medical and social services.
1993-1994. Geneva, WHO/Global Programme on AIDS, 1995.
13 Bhat G et al. Same day HIV voluntary counselling and testing improves overall acceptability among prenatal women in
Zambia. 1998. Abstract no. 33283, XII international Conference on HIV/AIDS, Geneva, Switzerland.
8
aBHIIHIBIIII May 2000
UNAIDS Technical Update- Volunl.iry Coumclling and TftUtng (VCT)
ft
n
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■
_____ ' »■<
■ ?. iQ'
8
■
■
■
■
Responses
will be common,
Integrating VCT services into other
existing health and social services
may also help to reduce costs and
make services available to a wider
range of people.
Cost sharing has been used in
some countries to help provide a
more sustainable service. In
Uganda, where the AIDS
information centre provides VCT,
clients are expected to pay a
share of the costs. One day a
week is set aside for free testing,
to enable people who are unable
to pay to still have access to VCT.
When this was introduced it did
not lead to a decline in testing.
Social marketing of VCT has also
been proposed as a way of
increasing access to sustainable
VCT services and has been
successfully implemented in
Zimbabwe.
Challenging stigma and
improving education
and awareness
In countries where stigma and
discrimination have been
challenged with political and
financial commitment, VCT has
been an Important component
of the process. However, in
many communities HIV remains
a stigmatizing problem and VCT
is not recognized as being an
important part of HIV prevention
and care. Societal attitude
towards HIV can have a strong
impact on individual choices,
and if people known to have HIV
face discrimination and stigma,
VCT is unlikely to be a popular
intervention. Stigma and
discrimination must be
challenged by government and
in communities.
Greater involvement of people
living with HIV/AIDS in
developing and promoting VCT
and providing education and
awareness about its benefits can
be important in providing a
more relevant service.
Legislation to protect the rights
of people living with HIV in
employment and education and
to prevent discrimination, need
to be in place if people are to
feel comfortable and secure
about seeking VCT. Mandatory
testing should also be
discouraged
Although there are public health
benefits of partner notification,
making this a compulsory
component of VCT has not been
shown to be helpful, and may
lead to discrimination of the
infected partner.
Promotion of the benefits of
VCT
The benefits of VCT arc often
not widely known and
understood. Promotion of the
advantages of VCT should be an
integral part of HIV education
programmes and included in IEC
materials.
VCT without associated support
and care services has been
sh< vn to be unpopular in many
settings. An explicit policy of
care and support for people
following VCT should be
developed in conjunction with
VCT.
If VCT services are to be effective, some important considerations include:
The location and opening hours of the service should reflect the needs of the particular community
j
VCT has been carried out in STI clinics, hospital outpatient departments .»nd hospital wards, but
also in centres specially dedicated to HIV counselling.14 VCT services for sex workers, as well as
condom supplies, are sometimes offered in the vicinity of nightclubs and operate at night.15
Counselling sessions need to be monitor cd to ensure that they >i<; «>t high guality and that
informed consent is always sought and counselling offered bt.-f< i<. i • I. .>> lake; .in HIV te I
a!
Counselling should be integrated into other services, including Sil, anh ..atal and lainiiy | i.u
clinics. Community-based counselling services should be initialed anti expanded.
W
A referral system should be developed in consultation with NGOs, community-ba-.cl
a,
hospital directors and other service managers, as well as with networks ol people living wii.li HIV
and AIDS. Regular meetings among service providers should be held to review and impiove the
referral system. »
IK
Counsellors need adequate training and ongoing support and supervision to ensure that they give
good-quality counselling and can cope with their stresses and avoid burnout. Development of
tools for monitoring the quality and content of counselling and counsellor needs would be useful.
j
i.. j
,4
,
14 Sittitrai W and Williams G. Candles of Hope: The AIDS Programme of the Thai Red Cross Society, London, TALC (Strategics fur Hope
No. 9), 1994.
15 Laga M., el al. Condom promotion, sexually transmitted disease treatment and declining incidence of HIV-1 infection in
female Zairian sex workers Lancet, 1994, 344(891Z):246 8.
Voluntary Counselling and Testing (VCT): UNAIDS Technical Update
May 2000
?;
in
1?
K
,r
-
.
.
....
■
If VCT services are to be effective, some important considerations include: (con t.)
t
Innovative ways of scaling up VCT services and making them more accessible and available should
be explored. Interventions to prevent MTCT have provided an important impetus to make VCT more
widely available for women and their partners. Pre-test group information can reduce the costs an
staff needed for VCT, but individual or couple counselling should also be available.
N
«
r»
New testing methods such as simplc/rapid testing will make VCT more available, especially in rural
areas and where laboratory facilities do not exist. Quality control, basic training and supply systems
need to bo organized to ensure that these services are delivered safely and appropriately.
Home testing and self testing are likely to be more commonly used. This will provide greater access
to VCT for people who are reluctant to attend formal VCT services. However, it is important that
adequate information about and provision of follow-up support services are available. (
Linkages to crisis support, follow-up counselling and care for those testing seropositive, and
strategies to enable people who tost seronegative to stay negative, should be developed.
1
Development of VCT for
specific groups
When VCT services are being
developed consideration should
be given to tlie different needs of
die people attending and the
communities for which the VCT
services are designed.
VCT for prevention of motherto-child transmission
Counselling and testing can
benefit women who are or who
want to become pregnant
Ideally, women should have
access to VCT before they
become pregnant so that they
can make informed decisions
about pregnancy and family
planning. For women who test
seropositive, counselling can
help them decide whether or not
to have children, and help
explore family planning options.
For women who are already
pregnant and who test
seropositive, counsellors can
help them make decisions about
terminating their pregnancy if
abortion is a safe, legal and
acceptable option. For women
who choose to continue with
their pregnancy, counsellors can
discuss the use of interventions,
such as short-course zidovudine
(ZDV, also known as AZT), to
reduce the risk of transmitting
HIV to the unborn child, if this Is
available. Infant feeding choices
can also be discussed.16 Where
possible, and when the woman
agrees, partners should be
involved In counselling sessions
in which decisions about their
present and future children are
being discussed and made.
Counselling services for women
should not be confined to those
associated with MTCT
interventions. Services should
reflect the multiple roles and
responsibilities of women and
embrace a comprehensive
approach to meet the health
needs of seropositive women.
VCT for couples
shown to be a successful
approach in some countries.17 -18
During pre-test counselling
couples can discuss what they
propose to do depending on their
test results and thus help prepare
the couple for their results. Post
test counselling helps the couple
understand their HIV test results.
If a couple has serodlscordant
test results this can pose difficult
challenges In the relationship.
Counselling can help the couple
overcome feelings of anger or
resentment (which In some cases
can lead to violence, particularly
against women). Counselling is
important to help couples accept
safer sex practices to prevent
transmission to the uninfected
partner.
t
Couple counselling for HIV can
also be provided as part of pre
marital counselling, and can
continue after the testing is
completed.
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testing. American Journal ol Public Health, 1993. 83:705-10.
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VCT for children
Counselling and testing can be
provided to couples who wish to
attend sessions together before
and after testing. This has been
16 UNAIDS. Mother-to->------- ---------------------17 Allen S et nl Confidential HIV totting and condom promotion In Africa. JAMA, 1&92' 8 3338-3343.
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infected, or they may be part of a
family in which one or both of
the- parents are either infected or
have died of AIDS.
When children have clinical signs
suggestive of possible HIV
infection, VCT can provide a
confirmatory diagnosis. The
counselling sessions may include
both the parents and the child.
HIV positive children have special
counselling needs such as
understanding and coping with
their own illness, dealing with
discrimination by other children
nr adults, and coping with the
illness and deaths of other HIVinfected family members. HIV
negative children who are
affected by HIV through the
illness of a parent or sibling also
have special counselling needs,
such as coping with the
emotional trauma of seeing their
loved ones ill or dying and
dealing with social stigma related
to HIV Older children may need
counselling related to
developmental issues (such as
sexuality and the avoidance of
risk behaviours) or coping with
and healing from childhood
sexual abuse that has put them
at risk for HIV infection. In all
cases, counselling provided to
children should use ageappropriate educational and
counselling methods.
VCT for young people
Teenagers are often particularly
vulnerable to HIV Infection. For
VCT services to be effective for
young people they must take into
account the emotional and social
contexts of young people's lives,
such as the strong influence of
peer pressure (e.g. to take drugs
or alcohol) and development of
sexual and social identities. They
aho he 'user fiicndly",
t ff h<» i in non threatening, safe,
irz-r'-.sib'e environments.
C.oun‘oiling should ho ageappropriate, using examples of
situations that are familiar and
relevant to youth, and language
that is non-technical and easily
understood.
Anonymous VCT services may bo
preferable for some young
people. However, different
countries and cultures may have
their own legal requirements and
social expectations that prevent
young people from accessing
VCT services without parental
consent or notification. Although
VCT services must always take
into account any relevant laws
regarding the rights and
autonomy of minors and the
responsibilities of parents for
their children, they must also
remember that the dignity and
confidentiality of the young
persons must be protected and
respected.
VCT for injecting drug users
Services targeting injecting drug
users (IDUs) must take into
account several factors. Injecting
drug use is a practice that is
illegal and socially stigmatized in
many cultures. Because many
drug users have experienced
social stigma and unpleasant
encounters with the law, they
may distrust or fear government
based or hospital-based social
services. VCT services that are
part of such institutions may.
therefore, be unlikely to attract
drug-using clients. Examples of
more successful VCT programmes
for drug users are those
coordinated with existing HIV
prevention and social service
outreach programmes that go to
the places that drug users
frequent. Often, the outreach
workers are former drug users
themselves, so they can
understand the drug culture's
particular social norms and
values. Also, because they have
already established trust with the
drug using community,
perceived as being more
credible. Such outreach workers,
when trained as HIV counsellors,
can explain HIV testing and the
importance of knowing one's
status in terms with which the
drug users are familiar and which
they can accept.
While HIV counsellors should
discuss risk reduction with their
clients at both pre- and post-test,
they should also understand that
IDUs may not be willing or able
to change certain behaviours,
such as their drug use or having
unprotected sex. In these cases,
HIV counsellors should discuss
safer methods of practising these
behaviours - such as not sharing
needles or sterilizing needles and
syringes before sharing - in order
to prevent the clients from
becoming infected or spreading
their HIV infection to others.
Counselling for sex wor kers
VCT for commercial sex workers
need to be sensitive to the
problems of stigma and illegality
associated with commercial sex
in many societies. Sex work is
usually the client's livelihood and
thus stopping some or all risk
behaviours may reduce the sex
worker's ability to earn a living.
Furthermore, sex workers may be
under considerable pressure to
perform especially risky activities
(e g. sex without a condom),
either through financial
inducement or coercion by a
pimp or client. Counsellors must
understand these issues, and
help the sex worker find ways to
work around or reduce the
obstacles they face when trying
to reduce their risk. In some
cases, counsellors may want to
work closely with community
organizations that empower and
support sex workers' desire to
keep themselves healthy and
safe.
counselling and prevention
messages delivered by such
outreach workers are often
11
Voluntary Counselling and Testing IVCT) UNAIDS Technical Update
May 2000
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Selected Key Materials
B
Baggaley R et al. HIV counselling
and testing in Zambia: The Kara
Counselling experience. SAFAIDS.
1998 6 (2):2-9.
UNAIDS. Knowlego is power,
UNAIDS. Best Practice Collection.
Case Study. Geneva, UNAIDS,
Kamenga MC et al. The voluntary
HIV-1 counselling and testing
efficacy study: Design and
methods. AIDS and Behaviour,
2000, 4(1): 5-14.
UNAIDS. Mother-to-child
transmission of HIV UNAIDS, Best
Practice Collection. Technical
Update. Geneva, UNAIDS,
Mugula F et al. A communitybased counselling service as a
potential outlet for condom
distribution. Abstract WeD834,
9th International Conference on
AIDS and STD in Africa, Kampala,
UNAIDS. UNAIDS policy on HIV
testing and counselling. Geneva,
UNAIDS, 1997. UNAIDS/97.2.
Statement encouraging increased
access to voluntary HIV testing
and counselling services that
feature informed consent and
confidentiality, quality assurance
and safeguards against potential
abuse.
Uganda, 1995.
Sittitkai W and Williams G.
Candles of Hope: The AIDS
Programme of the Thai Red Cross
Society. London, TALC (Strategies
for Hope No. 9), 1994.
Sweat ML et al. Cost-effectiveness
of voluntary HIV-1 counselling and
testing in reducing sexual
transmission of HIV in Nairobi,
Kenya and Dar Es Salaam,
Tanzania: the voluntary HIV-1
counselling and testing efficacy
study. Lancet, 2000, July.
UNAIDS. Caring for Carers,
managing stress in those who care
for people with HIV and AIDS.
UNAIDS, Best Practice Collection.
Case Study. Geneva, UNAIDS,
June 1999.
October 1998.
UNAIDS. Tools for evaluating HIV
voluntary counselling and testing.
UNAIDS, Best Practice Collection.
Key Material. Geneva, UNAIDS,
May 2000
planning and setting up
counselling services. Describes
counselling in the context of an
overall response to the epidemic,
and ways counselling is
organized.
WHO. Revised recommendations
for the selection and use of HIV
antibody tests. Weekly
Epidemiological Record (1997)
72:81-83.
WHO. Source book for HIV/AIDS
counselling training. Geneva,
Woild Health Organization,
(dohal Frograinine on AIDS
1994 Wl IO/( 4W it:C)/l i<
94.9 In:-.i.d 1 i'-i o' > 1,1 I '
coiifirellurs. De.ils '..itii iimi
training .»nd reficshvf cot*.
i- ■
those needing to aut as
counsellors in the course of tiicu
professional duties (e.g. health
care providers) and for those
specialized in counselling.
WHO. The importance of simple/
WHO. Counselling for HIV/AIDS
A key to caring. Geneva, World
Health Organization, Global
Programme on AIDS, 1995.
WHO/GPA/TCO/HCS/95.15.
Explores programmatic and
policy issues with regard to
rapid assays in HIV testing.
Weekly Epidemiological Record
(1998) 73:321-327.
May 2000.
© Joint United Nations Programme on HIV/AIDS (UNAIDS) 2000 AH rights reserved. This pubhcadon rnay be freely
duced or translated. In part or in full, provided the source is acknowledged. It may not be sold or used in conjunction with
F °$
without prior written approval from UNAIDS (contact: UNAIDS Information Centre. Geneva see page 2 ) The views impressed n documents by
named authors ere soWy the responsibility of those authors. The designations employed and the presentation of the material in this work du
not Imply the expression of any opinion whatsoever on the part of UNAIDS concerning the legal status of any country, lerritory, city or a ea o
of Its authorities^ concerning the delimitation of its frontiers and t^undaries The mention of specific companies or of certain manufacturers
do not 'itnpl, that the, are endo.tad o, recommondap by UNAIDS In p,o(e.ence to others ot a similar nature that roe not rnent,. mud
Errors and omissions excepted, the names of proprietary products are distinguished by Initial capital letters_________________________
May 2000
3
UNAID^vchmcal Update; Voluntary Couniclling and TeslingjyCT^
The Lutheran World Federation
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A Communion of Churches - Eine Kirchengemeinschaft - Una Comunion de Iglesias - Une Communion d’Eglises
Lutherischer Weltbund - Federacion Luterana Mundial - Federation Lutherienne Mondiale
2005 Christmas Message from the LWF President
Dear Sisters and Brothers in the worldwide Lutheran communion,
,5
“Do not be afraid.” So began the angel’s announcement of Jesus’ birth. It was also
Gabriel’s greeting to a bewildered Mary, “Do not be afraid.” To the grieving women at
Jesus’ tomb, angels again declared, “Do not be afraid.” To exiles in Babylon who felt
forsaken by God comes the announcement, “Be strong, do not fear!” (Isaiah 35:4)
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© Dar Al-Kalima School*
To be human is to have fears. Fear has permeated life in this past year and haunting
images will remain with us. Children fear abandonment as their parents die from
HIV/AIDS. Parents clutch their children, terrified there will not be food enough to keep
P.O. Box 2100, Route de Ferney 150,
CH-1211 Geneva 2, Switzerland
Tel +41/22-791 61 11
Fax +41/22-791 66 30, E-mail info@lutheranxvorld.org
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death and disease away. People struggle for survival in the midst of natural disasters.
Others seek safety from violence. All know the reality of fear.
We know the reality of fear, but fear must not become our defining reality. When fear
becomes our orientation to the world, we either withdraw in isolation or lash out in acts
of aggression. Fear hardens lives, dares not acknowledge failures, and closes borders. Fear
leaves us cynical, immobilized, and turned in upon ourselves.
The angel says, “Do not be afraid. For see, I am bringing you good news of great joy for
all the people: to you is born this day in the city of David a Savior, who is the Messiah,
the Lord.”
God sends messengers to hold back the walls of fear. We can then hear the good news of
God’s love in Christ Jesus for the whole creation. We entrust our lives to God’s promise.
Faith rather than fear defines us.
Faith frees us to confess our bondage to sin and to accept God’s gift of forgiveness. Faith
calls us to take up our cross and follow Jesus into our suffering world. Faith compels us to
bear witness to the signs of God’s reign of justice, mercy, and peace. As one writer said,
“Faith quells our fears, but never our courage.” We receive the future, trusting in the
power and promise of Christ’s death and resurrection.
May our voices in the communion of the Lutheran World Federation be joined with the
chorus of every time and every place as we joyfully sing:
Glory to God in the highest heaven,
and on earth peace
among those whom [God] favors.
In God’s grace,
Bishop Mark S. Hanson
President, The Lutheran World Federation
November 2005
* This year’s Christmas card, titled aHope”, was designed by fifteen-year-old Ramez Odeh from
Bethlehem. Ramez attends the Lutheran Dar Al-Kalima School in Bethlehem, West Bank.
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Practical information
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^WlVERSITE DE GENEVE
Admission
Applicants are accepted on the basis of their previous studies and
experience
■ an academic degree or equivalent,
■ at least three years of professional experience in humanitarian, social,
development or human rights related fields.
FORMATION CONTINUE
ENACTION HUMANITAIRE
ADVANCED STUDIES
IN HUMANITARIAN ACTION
Language
Courses are taught in both French and English.
Participants must speak and write one language correctly and have a
good knowledge (passiv) of the other language.
Selection procedure
Applicants are selected on the basis of their application file.
The number of participants is limited.
Ja n u a ry
Costs
e Tuition fees
Per module: CHF 4'000.
Whole programme : CHF 15'000.■ Living expenses in Geneva
Housing, transport,food, insurance, etc. vary between CHF 1'500.-to
2'000.- per month. Participants must find their own sources of finance.
Information on Geneva can be found on the following website :
http://www.geneve.ch/portail/
December
2 0 0 5
Faculty of Medecine
Faculty of Law
Faculty of Sciences
Faculty of Economics and Social Sciences
Certification
Participants who have fulfilled the requirements outlined in the program’s
rules and regulations will be awarded the Diplome de formation continue
en Action humanitaire /Master’s in Humanitarian Action by the University
of Geneva. Upon request, attestation may be obtained for each module
successfully passed.
Graduate Institute of Development Studies (iued)
Application
The application form can be found on the website of the program :
http://www.unige.ch/ppah
Complete files must be received before 15 September 2004.
PARTNERS
International Committee of the Red Cross (ICRC)
Information
Action humanitaire - ppAH
Universite de Geneve UNI MAIL
40, bd du Pont d’Arve / CH-1211 Geneve 4
Tel: +41 22 379 89 32
Fax : +41 22 379 89 39
Email: ppah@unige.ch
http://www.unige.ch/ppah
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Swiss Agency for Development and Cooperation (SDC)
International Federation of Red Cross and Red Crescent
Societies (IFRC)
Medecins sans frontieres (MSF)
Pan American Health Organization (PAHO)
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THE
HUMANITARIAN ACTION
PLURIFACULTY PROGRAM (PPAH)
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A training program:
Program
a in partnership with several humanitarian organizations,
■ designed for professionals,
■ to analyse contemporary situations and conceive
strategies for tomorrow.
A one year course (January until December 2005)
made up of 5 modules and a dissertation. Candidates
can follow modules according to a personalized timetable.
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Thematic modules
1
Tools for a Critical Approach of Humanitarian Action
This is a broad and complete introduction to humanitarian action
covering : philosophy, ethics and epistemology ; history and
geopolitics; economics and managerial aspects; environmental risks.
2
Law and Humanitarian Action
To understand the close links between law and humanitarian action
3
Public Health and Humanitarian Action
To present health as a core element within the framework of
humanitarian action and provides tools for analysis.
4
Humanitarian Crisis Management
To critically address the management of a humanitarian crisis,
whatever its origin.
Based in Geneva
Geneva's location as the world’s capital of humanitarian action and
the headquarter of many international organizations is quite
exceptional. This is an undeniable asset for humanitarian workers
who wish to further their theoretical and practical knowledge.
Objective
To take advantage of the academic context to master the conceptual
and methodological tools that are indispensable in order to address
the great humanitarian challenges of our time.
Pedagogical methods
In our approach to teaching, we emphasize interactivity and a
critical and independent examination of the meaning of
humanitarian action and how it is carried out.
5
From Emergency to Development
To look together at ways of anticipating emergencies, in order to
reduce the gap between the short and long term, and between
emergency management and development.
Dissertation
Students complete the Diploma by writing a Master’s dissertation.
Teaching Staff
Faculty staff from Universities of Geneva, Switzerland and Europe
as well as experts from international organizations and NGOs
actively involved in humanitarian action.
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Internship
Students can do a three-month (minimum) internship in one of our
partners’ organizations.
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