World Council of Churches

A worldwide fellowship of churches seeking unity, a common witness and Christian service

CHAPTER 2 The scientific facts: an introduction

CHAPTER 2, The scientific facts: an introduction

01 January 1970

Diseases emerge or re-emerge in different parts of the world from time to time. Occasionally a disease is "discovered" which may in fact have been prevalent for some time. Such phenomena have in general been limited geographically to certain ecological niches where conditions were conducive for the "new", emerging or re-emerging disease. AIDS, by contrast, is truly a new disease. Its ecological niche seems to cover the whole world. In its wake it has brought many surprises. It has shocked us into reflection.

AIDS stands for

Acquired (not genetically determined)

ImmunoDeficiency (severe depletion of immune system cells, that
is, the cells which defend the body from other, even trivial,
infections)

Syndrome (an illness which presents itself in various forms)

The origins of AIDS are unknown; however, it was first recognized in the USA during 1981. Initially it was reported among gay men, and was causing death at an. early age. These two aspects were publicized sensationally by the mass media worldwide, etching the notion "AIDS = gay plague" on the minds of people everywhere. The aversion and fear which this notion promoted have remained, despite clear evidence to the contrary. After gay men the next most commonly stereotyped group to be affected was intravenous drug-users, thus further reinforcing negative attitudes.

Such prejudices are still alive today, although more and more groups are being affected. AIDS increasingly strikes women, children, heterosexuals, and those who have not been sexually active. It` strikes not just persons "out there", but members of local communities, familiar neighbours and even family members. Sadly, many Christians and some churches have shared in the promotion of negative, judgmental and condemnatory attitudes.

By 1982, AIDS had been detected in some African countries (in fact, it was found to have been responsible for high fatality rates there since the 1970s). It was affecting heterosexuals, both men and women, who were neither homosexual nor injecting drug-users. Thus AIDS was known to be transmitted by sexual contact - regardless of gender - and by blood (for example, through needle-sharing or blood transfusions). It also became clear that sexual transmission was related to having many sexual partners. This new connection with sexual promiscuity entrenched self-righteous, negative judgments about people living with HIV/AIDS.

In 1983-84 the virus causing the immunodeficiency was identified. Although previously known by other names, it is now called HIV (Human Immunodeficiency Virus). It has continued to spread without detection among many people in new places. By the time this report was completed, HIV infection had reached nearly all countries of the world; and families everywhere are beginning to be affected by AIDS. It has thus become a pandemic. For people in towns, villages and parishes, it is causing local epidemics. The infection and disease, at first an epidemic (referring to a disease with a rapid and increasing rate of spread), are becoming endemic , that is, entrenched and spreading steadily. Epidemics go away; endemic diseases remain.

The chain of transmission of HIV/AIDS is not at all limited to persons having sexual contact with multiple partners.

  • A spouse living in a faithful monogamous sexual relationship may become infected if his or her partner was infected earlier, either through sexual contact or needle-sharing drug use.
  • HIV has spread and continues to spread in health-care settings due to unscreened blood transfusions and the reuse of needles and syringes without adequate cleaning and sterilization.
  • Infants born to HIV-infected women are also at risk of becoming infected with HIV. This is called "vertical" transmission. Between 15 and 40 percent of infants born to HIV-infected mothers develop HIV infection through vertical transmission.

HIV infection is a silent phenomenon which can be diagnosed only by blood tests. By itself it is not a disease. However, infected persons remain internally virus-infected for life, and they are therefore infectious to others through blood or other body-fluids contact. As a result of prolonged HIV infection the immune system weakens, and as a result of this immune deficiency the person becomes susceptible to secondary diseases. This phase, marked by opportunistic infections, cancers or other debilitating conditions, is generally called HIV disease or AIDS.

In spite of intensive biomedical research no cure has been found for the immune deficiency caused by HIV infection. Although several anti-viral drugs have been developed, the virus has developed resistance against all of them. This is partly due to the ability of the virus to mutate and change through a process of adaptation. As a result of such changes the virus has differentiated into subtypes in different geographical regions. Continuing attempts to develop an effective vaccine against HIV infection have also been unsuccessful so far; and it is generally believed that a single vaccine may not be effective against all subtypes. In short, a biomedical cure or vaccine for HIV/AIDS remains an elusive goal.

At the individual level, HIV infection is potentially preventable if one avoids the risk factors which facilitate the transmission of infection. In sexual activity, partners exchange sexual secretions and, along with them, microbes that are normally present in abundance on the genital mucosal surfaces. These are called the normal microbial flora; we acquire them normally from our environment during the physiological processes of growth and development. Having sex with a single partner in mutual monogamy ensures that both partners have only the normal flora.

Pathogenic microbes that cause diseases such as syphilis, gonorrhoea, genital herpes, chancroid and so on can be acquired only from another infected person through sexual contact. These are known as sexually transmitted diseases (STDs). Because HIV is sexually transmitted, AIDS is also an STD. Unlike most sexually transmitted diseases, HIV/AIDS does not cause disease of the local genital mucosa and skin. However, the presence of an STD, particularly one with an ulcerative lesion, facilitates the transmission of HIV between sexual partners if one of them has the infection. Since HIV is transmitted less readily and less often in the absence of any local lesion, the early detection, diagnosis and correct treatment of all other STDs will reduce the risk of HIV transmission, even when one of the partners is infected with HIV.

The chance of sexual transmission of any pathogen, including HIV, is minimal or none if an effective barrier is used to prevent physical contact between the mucosal surfaces of the sex partners. The barrier also prevents the exchange of genital secretions. This is the principle behind the use of condoms to prevent HIV transmission. The condom is to be worn by the male partner; a condom to be worn by the female partner has also been designed and field-tested.

The magnitude of the problem

When AIDS emerged two decades ago, few people could predict how the epidemic would evolve. We know now from experience that AIDS can devastate whole regions, wipe out decades of national development, widen the gulf between rich and poor nations, and push already stigmatized groups closer to the margins of society. Experience also shows that the right approaches, applied quickly enough and with courage and resolve, can and do result in lower HIV infection rates and less suffering for those affected by the epidemic.

The Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization (WHO) estimates that the number of people living with HIV or AIDS by the end of the year 2000 stood at 36.1 million. [1] Already 21.8 million people around the world have died of AIDS, 4.3 million of them children. The most recent estimates show that, in the year 2000 alone, 5.3 million people were newly infected with HIV. This pandemic has also orphaned 13.2 million children.

Of the 36.1 million people with HIV/AIDS, 25.3 million (70 percent) live in sub-Saharan Africa . In sixteen countries in this region over 10 percent of the people are infected with HIV, and in six of them 20 percent are infected. Successful prevention programmes in a handful of African countries, notably Uganda , have reduced national infection rates and show the way ahead for other nations.

The region of South and Southeast Asia is estimated to have 5.8 million adults and children living with HIV or AIDS. In East Asia , most of its huge adult population has an HIV prevalence rate of 0.07 percent, as compared with 0.56 percent in South and Southeast Asia . The epidemic in East Asia has ample room for growth as there is a steep rise in the incidence of sexually transmitted diseases in the region.

In Latin America and the Caribbean 1.8 million people live with HIV/AIDS. The epidemic in this region is a complex mosaic of transmission patterns in which HIV continues to spread through homosexual transmission.

In Eastern Europe and Central Asia the estimated number of adults and children living with HIV or AIDS at the end of 1999 was 420,000. Just one year later, a conservative estimate put the figure at 700,000. Most of the quarter million adults who became infected were men, the majority of them injecting-drug users.

There is compelling evidence [2] to show that the trend in HIV infection will have a profound impact on future rates of infant, child and maternal mortality, life expectancy and economic growth. These unprecedented impacts at the macro-level are matched by the intense burden of suffering among individuals and households. Caring for those who are infected remains an enormous national and international challenge. Caring for the orphans the epidemic has left behind compounds this task. Protection of another generation of young people from premature illness and death is a responsibility of the highest order.

Prevention of HIV transmission

The magnitude of the problem and the current speed of expansion of the HIV pandemic make prevention a primary concern.

Since the beginning of the pandemic, knowledge about the best methods of preventing the transmission of HIV has increased tremendously. The learning process has been difficult and painful. Many approaches have been unhelpful or even damaging, and the implementation of effective methods has often been slow, or has suffered from insufficient funding. These obstacles have cost the lives of countless people. After careful evaluation of the successes and failures of many approaches and programmes, a number of effective interventions are now available. These include the following.

1. Information, education, communication

The prevention of HIV transmission requires first and foremost that people are properly informed about how the virus can - and cannot - be transmitted from one person to another. Understanding these facts should enable people to make responsible choices that will prevent this transmission. But information alone is not enough to determine human behaviour, which is related to deep emotions, to socio-economic conditions and to cultural and traditional norms and values. And in many situations freedom of choice is absent, so that persons are prevented from acting wisely.

Participatory approaches are required in which education is linked to experience. Key elements to be borne in mind in planning information, education, communication programmes are:

  • the educational messages must be clear and easy to comprehend, using appropriate media targeted specifically on the groups to be educated;
  • the most effective educators are people directly affected by HIV/ AIDS;
  • the community must be involved in identifying the cultural and social practices which increase or decrease the risk of HIV transmission, and in formulating education programmes appropriate for its situation;
  • peer groups - persons from the same age range who are acquainted with the social and cultural environment of the target groups - are much more effective in education than people coming from "outside".

Generally speaking, messages using fear and negative images of AIDS have not been effective in producing or sustaining changes of behaviour.

2. Reduction of sexual transmission

Sexual transmission of HIV can be prevented by avoiding sexual behaviour which leads to an increased exposure to HIV. The safest options are sexual abstinence or mutual faithfulness in stable sexual relationships. If these options are not possible for some people, the proper and consistent use of latex condoms offers a high degree of protection against HIV and other sexually transmitted diseases (see pp.60-62, below).

3. Early diagnosis and treatment of other sexually transmitted diseases

Since infection with other sexually transmitted diseases greatly increases the risk of HIV transmission, early diagnosis and effective treatment of these diseases is an important method of risk reduction.

4. Safe blood transfusions

HIV can be transmitted in health-care settings by the transfusion of blood from infected to uninfected persons. This risk can be minimized by giving transfusions only when necessary, avoiding them in situations in which alternative treatments suffice. All blood to be transfused should be tested and found negative for antibodies against HIV.

5. Proper sterilization of needles and other skin piercing instruments

Scalpels, needles, razor blades or traditional instruments which have been contaminated with HIV carry the risk of transmitting the virus if they are used to penetrate the skin of uninfected persons. Sterilization using standardized techniques can prevent this way of transmission.

Health-care institutions must establish strict policies and practices for the prevention of all nosocomial (hospital-acquired) infections.

6. Provision of sterile instruments for users of intravenously applied drugs

Needle-sharing by injecting drug users is another risk factor for HIV transmission. The availability of individual equipment for injecting, disinfection of equipment before usage and needle exchange programmes can remove the risk of transmission of HIV and of other blood-borne infections such as viral hepatitis B or C (see pp.62-63 below).

7. The link between care and prevention

Comprehensive physical, emotional and spiritual care for persons living with HIV/AIDS has been shown to be a very important and effective contribution to prevention. Appropriate care is a precondition for gaining their confidence and co-operation; and a comprehensive process of care helps families and communities to face the issues raised by HIV/AIDS and to consider and understand its implications for themselves (see pp.83-85 below).

8. Reducing discrimination

Stigmatization of persons because of their social status, sexual orientation or addiction to drugs makes them more vulnerable to risks, including the risk of infections. If such persons feel excluded and are afraid of having their identity revealed, they are less likely to seek care and counselling, to have access to health information and to cooperate with AIDS prevention programmes. Thus resistance to all forms of discrimination and advocacy for the rights of people who are vulnerable to HIV are not only ethical demands but also a contribution to effective prevention (see below, pp.58 and 74).

9. Empowerment of persons who are particularly vulnerable

Persons who have no power to make decisions about their own bodies in regard to sexual relationships are at a far greater risk of being infected with HIV, even if they have received effective education for prevention. This applies particularly to women, who must be empowered to resist cultural and economic pressures to engage in unwanted sexual relationships (see the "Ecumenical Platform of Action - Women's Health and the Challenge of HIV/AIDS", pp. 17-18).

10. Prevention of HIV transmission from mother to child

Anti-viral treatment of pregnant women and their new-born children has recently been shown to reduce by about two-thirds the risk of vertical transmission. However, this treatment is not yet universally available because of its high cost.

Socio-economic and cultural contexts

Socio-economic and cultural contexts are determining factors in the spread of HIV/AIDS. Because these circumstances differ from place to place, countries, districts and even villages may have quite different HIV/AIDS stories and current profiles. But 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 discrimination are prevalent.

Development practice with respect to HIV is paradigmatically the practice of human development. This is so for significant reasons. The focus of HIV is people's sexual, psychological and social relations and behaviour. No roads, fertilizers, procurement systems or stock exchanges are available to distract attention from or mask the fact that people are the focus of its practice.

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 labour mobility (which is more than the physical mobility of persons and includes the effects on values and traditional structures associated with the processes of modernization). At the core of the problem of transmission of HIV are issues of gender and poverty.

Thus, the classical components of development - transportation systems,' labour markets, economic growth, governance, poverty and more - are within the causal framework which determines the patterns and speed of spread of the virus. These components will also be affected by the impact of the spread of the virus, its associated mortality and morbidity and the burden of dependency and social disruption it will create, No longer can the implications of failures to alleviate poverty or success in employment be understood in isolation. All of the components of development affect what happens with the HIV epidemic.

Dr Elizabeth Reid, United Nations Development Programme,
H/V anti Development Programme

At the root of the global socio-economic and cultural problems related to HIV/AIDS are the' unjust distribution and accumulation of wealth, land and power. This leads to various forms of malaise in human communities. There are more and more cases of economic and political migration of people within and outside of their own countries. These uprooted peoples may be migrant workers looking for better-paying jobs or refugees from economic, political or religious conflicts. Racism, gender discrimination and sexual harassment, economic inequalities, the lack of political will for change, huge external and internal debts, critical health problems, illicit drug and sex trades, including an increase in child prostitution, fragmentation and marginalization of communities - all these factors, which affect "developed" as well as "developing" societies, form a web of interrelated global problems which intensify the vulnerability of human communities to HIV/AIDS.

The family and AIDS

The family is a basic social unit of human relations. Through the family, persons are nurtured and sustained in mutual love and responsibility. In different places and circumstances the family exists in various forms: as a traditional nuclear family in a "household", or as an extended family, or as a family of choice. But whatever the form, HIV/AIDS touches the life, behaviour and perspectives of people in human families.

Human families are challenged continually by their socio-economic and cultural context, and by the phenomena of globalization and fragmentation, which contribute to the current fragility of human relationships. In many societies the fabric of family and community life is weakened by the imbalance of power between men and women - an imbalance which starts from the moment of birth. Often the "shared responsibility" for maintaining the social fabric falls on the shoulders of girls and women, who in many cultures however remain subordinate to men. To this imbalance of power is related the failure of men to take responsibility for issues related to sexuality, reproduction and HIV/AIDS.

Most people living with HIV/AIDS are in the prime productive and reproductive age group of 15 to 44 years. About half of all HIV infections occur among young people below 24 years of age, indicating the inherent vulnerability of youth in most cultures, a fact which is constant even though there are many different contexts within each culture.

An international ecumenical youth meeting held in Namibia in 1993 identified three of the biggest concerns for teenagers worldwide as relationships with peers, changing relationships with parents and families, and the experience of newly-found identities and sexuality. Young people feel the need to belong and to be accepted by those with whom they identify. Many of these relationships are creative, but peer pressure may lead to experimentation with sexuality and with the use of alcohol and drugs, [3] exposing them to HIV/AIDS risk factors. Often the problems are compounded by the attitudes and policies of community leaders. For example, a staff member of the WHO specializing in issues of youth and AIDS has noted that "the opposition of political and religious leaders (not to mention parents and teachers) to open and objective discussion of AIDS education for young people makes implementation of innovative and potentially effective interventions difficult, and sometimes impossible, worsening the situation". [4]

The vulnerability of young people, especially young women, reflects the current fragility of the roles constructed by each society for males and females from childhood on. Whenever gender discrimination leaves women under-educated, under-skilled and unable to gain title to property or other vital resources, it also makes them more vulnerable to HIV infection. In 1980 an estimated 80 percent of people living with HIV were men, and 20 percent were women. By the mid-1990s the number of women living with HIV had increased disproportionately; a recent estimate is that 40 percent of people living with HIV are women.

Economic, social and cultural factors which perpetuate the subordination of women are contributing to the spread of HIV. In many societies the position of women limits their control over their bodies and their power to make decisions about reproduction. Women may be forced into commercial sex work by their own economic situation or that of their families. Faced with overwhelming poverty, a woman who works in a brothel may reason: "If I work here I may die in ten years. If I do not, I will die of starvation tomorrow."

In addition, women's traditionally important role as care-giver within their families and communities exposes them in different contexts to the burdens of HIV/AIDS. Many are providing loving, supportive care to their sick husbands, children, parents and extended family. The overwhelming burdens of this nurturing role are not often shared by men. Thus women are usually the last to seek medical assistance; either the resources are no longer sufficient, or they have no time to attend to themselves or they are too exhausted to go for medical care. And in the case of pregnancy, lack of prenatal care makes it difficult for a woman with HIV to reduce the chances of infecting her children.

Ecumenical Platform of Action
Women's Health and the Challenge of HIV/AIDS

The HIV/AIDS epidemic is affecting all aspects of people's lives. Economic, social Laid cultural factors which perpetuate the subordination of women are contributing to the spread of the virus and exacerbating its effects on the lives of women. We acknowledge the excellent work that is being done in many situations, but in general, strategies of prevention and care by governments, churches and non-governmental organizations have so far failed to influence the broader determinants of the situation of women.

What has this to do with the churches?

Where the church is silent in theface of injustice in the lives of the people, it is not being faithful to God's mission. The time has come, then, for the church to examine and assess the extent of its complicity in upholding the social structures that perpetuate women's subordination.

In some parts of the world, for instance, the churches have collaborated in the myth that the transmission of the AIDS virus is confined to commercial sex workers, homosexuals and drug users. This is untrue and damaging, and needs to be refuted...

We are a group of thirty people from five continents... All of us have practical experience in working with church programmes related to HIV/AIDS. Some of us are living with HIV/AIDS... All of us had found that this work had continually challenged our thinking, our attitudes and our theology, and had transformed our vision. In sharing our experiences and the results of our research, we found that we do have much in common; that we gain strength and confidence by exchanging perspectives; and thatthe issues we face - though from widely differing contexts - were very much the same. We were able to reach unanimous agreement about an ecumenical platform of action.

Platform of Action

  1. We call upon our churches to engage in self-critical examination of the churches' participation in and perpetuation of cultural biases and patterns that contribute to women's subordination and oppression.
  2. We urge our churches to create an environment where the life experiences of women can be heard without fear of judgment, in an atmosphere of mutual love and respect, so that the issues that emerge may be addressed.
  3. We strongly recommend that the churches re-evaluate the ways in which we have interpreted the Bible, along with church traditions and images of God. Many Christians have accepted these as truth without considering how far they are (or are not) rooted in people's daily realities and consistent with the liberating message of Jesus.
  4. We challenge the churches to acknowledge openly the sexual dimension of human experience and allow for this dimension to become part of ongoing church dialogue.
  5. We commend this platform of action to our churches worldwide in the to-ping hope that they will remember always, in their consideration; reflection and prayers, that these Issues do not have to do with abstract ideas but with real people, the quality of their lives and their well-being and health.

From a WCC AIDS Consultative Group workshop
in Vellore , India , 7 September 1995

The Joint United Nations Programme on HIV/AIDS (UNAIDS) has reported that in high-prevalence countries with a long-standing epidemic, AIDS has begun to wipe out achievements in child survival, to shorten life expectancy and to threaten the very process of development.

Families are torn asunder by the pain which HIV/AIDS brings as children become orphans, and as men and women die in their most productive years. Grandparents who should be retiring find themselves caring for the sick, as this story from a remote village in Tanzania brings out vividly:

I visited an old man... He was a respected man, being one of the first ministers ordained in his church some decades ago. He told me that his two daughters had died of AIDS. Being a widower, he was now solely responsible for looking after four grandchildren. He had to provide food and clothing for them and to pay for the school fees of the eldest granddaughter.

Receiving a small pension from his church, he was a little bit better off than countless grandparents all over the world who have to look after their orphaned grandchildren nowadays. But his house, which had almost collapsed, the signs of malnutrition in his grandchildren and the resignation on his face showed that he could hardly cope with this additional burden at the end of his life.

http://www.wcc-coe.org/wcc/what/mission/ehaia-html/app3.html

 


[1]   AIDS Epidemic Update , UNAIDS/WHO, Dec. 2000.

[2]   Report on the Global HIV/AIDS Epidemic , Joint United Nations Programme on HIV and AIDS (UNAIDS), June 2000.

[3]   See Joao Guilherme Biehl, Janet Kenyon, Siv Limstrand and Anu Talvivaara, eds, Making Connections: Facing AIDS, An HIV/AIDS Resource Book , Geneva , WCC, Unit III and Lutheran World Federation Office for Youth, 1993.

[4]   Chandra Mouli, Statement on "Youth and Aids: A Priority for Prevention", Minutes of the First Meeting of the Consultative Group on AIDS (1994) , Geneva, WCC, Programme Unit II, 1995, p.69.

 

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