The Continuing Crisis: A report on the church’s global response to H.I.V./AIDS
Dec. 1—World AIDS Day—marks 32 years since the first cases of AIDS were reported. This year also marks 30 years since three papers published in the journal Science (5/20/83) identified the causative agent of the epidemic: human immunodeficiency virus, now commonly known as H.I.V. For two of those publications, Luc Montagnier and Françoise Barré-Sinoussi, both of the Pasteur Institute in Paris, were awarded the Nobel Prize in Physiology or Medicine in 2008. Their discovery paved the way for a blood test to detect the presence of H.I.V. in 1985 and led to the development of the first treatment for the virus (AZT, or zidovudine) in 1987.
Since then, AIDS has been recognized as one of the greatest scourges of humankind, counted by the World Health Organization as the sixth leading cause of death in the world (1.6 million deaths in 2011) and by the Joint United Nations Programme on H.I.V./AIDS as the leading cause of death among women of reproductive age (15-44 years). The impact of the epidemic is seen not just in the individual lives that are affected. In 2001 the U.N. Security Council recognized the epidemic as a threat to global peace and security. H.I.V./AIDS impedes economic development and agricultural production and drains countries of human capital—the skills and resources of the youngest and often most productive members of society.
In 2010 the Centers for Disease Control and Prevention estimated that 1.15 million persons in the United States were living with H.I.V. infection—nearly one in five of them do not know they are infected—with another 636,000 having already died of AIDS. Although we have made tremendous strides in treatment, with access to more than 20 licensed H.I.V. drugs (sometimes available as one combination tablet of three to four drugs taken once daily), we have made little progress in preventing new infections. Approximately 50,000 Americans still acquire H.I.V. every year. Unfortunately, African-Americans bear a disproportionate burden of the epidemic. Although they represent only 14 percent of the population, they account for approximately 50 percent of all new infections in the United States.
The Joint United Nations Programme on H.I.V./AIDS estimated in 2012 that 35.3 million persons around the world were living with H.I.V. and that another 36 million had already succumbed to the disease. The number of new infections is slowing significantly, however; 2.3 million persons became H.I.V.-infected in 2012, compared with 3.4 million in 2001 (a decrease of 33 percent in just over a decade). The distribution of H.I.V. infections across the globe remains quite uneven, with sub-Saharan Africa accounting for only 12 percent of the world’s population but more than 66 percent of all new infections.
The Catholic Church Becomes Involved
What has been the church’s response to this unprecedented crisis? In the United States, Catholic hospitals, like the now-shuttered St. Clare’s and St. Vincent’s in New York City, responded heroically to this medical and pastoral emergency even before the infectious agent or its modes of transmission were known. During my residency at San Francisco General Hospital from 1983 to 1986, however, I was asked by nurses on Ward 5B to identify Jesuits from the city who could come to visit H.I.V. patients. Nurses explained they sometimes saw patients distressed by pastoral encounters they experienced as judgmental and harmful. Perhaps because of inexperience with affected populations or out of fear of contagion, some ministers focused their response to infected persons on a reiteration of the church’s teaching on homosexual activity and drug use, rather than asking those facing life-threatening illness how the church might help them to be reconciled with God.
These encounters made it clear that education and training were needed if the church’s ministers were to provide effective pastoral care unencumbered by fear or judgment. The first organization to provide such training in the late 1980s was the Lazaro Center in New York City, founded by Franciscans. By the early 1990s the National Catholic AIDS Network had also begun education and training. It taught pastoral ministers about the epidemic and about the particular needs of H.I.V.-infected persons; it worked to identify the resources within our faith tradition that can support those engaged in H.I.V. care; and it advocated for persons living with H.I.V./AIDS. Unfortunately, some 20 years after its founding, as successful treatments contributed to a declining public profile of the disease, the organization succumbed to a lack of funding. Today there is no national Catholic structure with AIDS as its mission, although diocesan- and parish-based programs continue.
In 1987 Caritas Internationalis, the Vatican-based network of 164 national Catholic relief and development agencies (of which Catholic Relief Services and Catholic Charities USA are members) identified H.I.V./AIDS as a priority by establishing a global working group on H.I.V./AIDS. The mission of the working group was to ensure that the church kept abreast of medical and scientific developments, visited high-impact countries, shared “best practices” and provided training for bishops’ conferences, clergy and religious orders on the particular challenges of responding to the crisis. Recognizing that the epidemic required deeper theological reflection, it convened meetings of indigenous theologians to reflect on the challenges of AIDS in Western Europe, the United States, Asia, Latin America and in English- and French-speaking Africa.
In the earliest years of the epidemic, the church responded with its tradition of pastoral care and accompaniment for individuals and families affected by H.I.V./AIDS, often led by religious sisters already on the scene. I worked in one such program in Masaka, Uganda, at the Irish Medical Missionaries of Mary’s Kitovu Hospital in 1996. Despite the fact that no specific H.I.V. treatments were yet available at the international level (except in the private market), the hospital had developed two well-organized teams that traveled to rural villages on a two-week cycle to provide education, pastoral care, nutritional support and palliative medications. The M.M.M. sisters served on the national AIDS committee, which developed guidelines for care, especially guaranteeing that all H.I.V. testing was done confidentially by highly trained staff who were able to provide the support needed for patients whose test results were unfavorable.
In 1995, recognizing the particular threat that H.I.V./tuberculosis co-infection posed to individuals and communities, especially combined with worsening tuberculosis resistance, Caritas convened a conference on TB care in the context of the H.I.V. epidemic. Participants were forced to challenge the church’s traditional understanding that “anything that could be offered is better than nothing,” as TB experts warned that this approach could cause greater harm because of the impact on communities if drug resistance spread. Rather than doing whatever little they could with meager resources, agencies learned that they must instead let individuals die of their infection if they could not guarantee a full TB treatment course. Indeed, in 2006 “extremely drug resistant TB,” largely a consequence of incomplete treatment, was first identified among H.I.V.-infected patients in the Kwazulu-Natal region of South Africa. The median survival time was 16 days after diagnosis.
While the church’s teaching on the use of condoms for contraception is clear, some prelates have argued that if individuals are going to violate the Sixth Commandment against illicit intercourse, they should not also violate the Fifth Commandment against killing. They accepted the use of condoms for that specific life-saving purpose. In 2001, in their pastoral letter “A Message of Hope,” the Southern African Bishops Conference criticized the use of condoms as a means of H.I.V. prevention but also addressed the problem married couples confronted when one partner was H.I.V.-infected: “The Church accepts that everyone has the right to defend one’s life against mortal danger. This would include using the appropriate means and course of action.” Comments by Pope Benedict in a 2010 interview also appear to indicate that when used solely to prevent H.I.V. infection, condoms might be viewed from a more nuanced perspective. The church “of course does not regard it as a real or moral solution,” he said, “but, in this or that case, there can be nonetheless, in the intention of reducing the risk of infection, a first step in a movement toward a different way, a more human way, of living sexuality.”
Globally, church agencies were initially hesitant to become involved in the business of providing H.I.V. drugs because of the cost and complexity of administering them. When the Global Fund to Fight AIDS, TB and Malaria and the President’s Emergency Plan for AIDS Relief provided billions of dollars to bring these drugs to low- and middle-income countries, however, Caritas again convened partners to make sure that Catholic agencies’ engagement with H.I.V. therapy met rigorous scientific standards and national treatment guidelines. Catholic agencies subsequently became major providers of H.I.V. drug therapy in many developing countries. In South Africa, for example, at a time when the president and the minister of health were denying that H.I.V. was the cause of AIDS, the Southern African Bishops Conference established 28 H.I.V. treatment centers with Global Fund and Pepfar support. Although rigorous statistics are not available, the Vatican has suggested that Catholic agencies may provide as much as 25 percent of AIDS care at the international level.
The Catholic H.I.V./AIDS Network
As Caritas eventually mainstreamed its attention to H.I.V./AIDS and ended its AIDS working group (and subsequent AIDS task force), a parallel structure that had been developed by Catholic development agencies stepped into the breach. Initially known as the AIDS Funding Network Group, this consortium had been formed to assist donor agencies in supporting AIDS programs by developing criteria to ensure that interventions met uniform ethical and programmatic standards. Over time this group evolved into the Catholic H.I.V./AIDS Network, based in Geneva under the leadership of Msgr. Robert Vitillo of the Diocese of Paterson, N.J. CHAN not only continues Caritas’s mission to maintain best practices and scientific rigor, it has also become what is perhaps the best-organized global AIDS network of any religious denomination. The Joint United Nations Programme on H.I.V./AIDS and W.H.O. now count on the experience of the church’s response as coordinated through this group, regularly meeting with its members and leadership to share experiences and to evolve guidelines and recommendations. In one of its most important accomplishments, CHAN worked successfully with pharmaceutical manufacturers to urge development of new formulations of H.I.V. drugs that could be dosed by weight for infants and children.
At the most recent meeting of CHAN, held in Geneva in mid-October, a mixture of emotions could be felt. There was excitement that W.H.O. had raised its target for providing AIDS treatment from 15 million to 26 million persons (10 million are currently receiving drugs) as a result of studies showing that H.I.V. treatment is the best way to prevent new infections (reducing transmission by up to 96 percent). It was also clear, however, that despite these admirable goals, the global economic crisis has led to severe funding crunches for the Global Fund. One round of funding was completely cancelled. The U.S. program Pepfar has also seen significant cuts in its funding, and it is reducing support for faith-based organizations as it asks countries to take on the responsibility for providing basic H.I.V. care. In southern Africa, this has already resulted in the closure of 22 southern African bishops’ H.I.V. treatment centers and three church-sponsored voluntary counseling and H.I.V.-testing centers in Namibia.
Despite the trend in some areas to fund state-sponsored, rather than faith-based treatment programs, the legacy of the church’s comprehensive approach has contributed significantly to a new model for responding to global health needs. The pre-AIDS-era “silo” model of externally funded, stand-alone programs (for example, only for vaccinations or only for treatment of TB or malaria) has given way to a new model that strives to provide comprehensive and community-based services. It is hoped that the lessons learned from scaling up treatment for H.I.V./AIDS will lead to a general strengthening of health delivery systems worldwide, bringing the promise of adequate care not just to those living with H.I.V. but to every member of the community.
This article has been revised to reflect the following correction:
Correction: Nov. 26, 2013
An earlier version of this article misidentified the year of the first blood test to detect the presence of H.I.V. It is 1985, not 1992.
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