HIV - More than a medical condition?

Ahead of World AIDS Day on 1 December, Martin Pendergast gave the following seminar at Derby Cathedral on 25 November 2013.

Martin Pendergast studied theology in Rome and Bristol. A qualified social worker, he has worked in the HIV/AIDS field since 1984, initially managing HIV-specific social work services in Lambeth/St Thomas’ Hospital, and in 1989 moving into NHS commissioning of HIV, Sexual Health, and Alcohol & Substance Use prevention and treatment provision in North East London. Since the early 1980’s he has been involved in a variety of local, pan-London, national and international faith-based responses to the HIV pandemic. He co-founded Catholic AIDS Link and its successor, Catholics for AIDS Prevention & Support (CAPS). He was a faith-advisory member of the Government’s Independent Advisory Group on Teenage Pregnancy for 5 years. He has been a Trustee of NAM-AIDSMAP since 1997, and also chairs the Centre for the Study of Christianity & Sexuality (CSCS). He lives in East London.

It is often said that the HIV pandemic fundamentally challenges a wide variety of institutional assumptions about sex and sexuality, the capacity of human behaviour for both positive development in autonomous choices, as well as more negative aspects of dependency and self-destruction. People of faith and their communities’ structures are amongst those so challenged, but only a few have risen to spelling out what the challenges might look like.(1) This pandemic, still, 30 years on, clearly and increasingly raises questions of social justice, equity, human rights, poverty, and the ‘isms’ of race and gender.(2) I believe our continuing global experience of HIV provides us with unique opportunities to undertake a broader analysis, thus grounding in concrete social realities any subsequent theological reflection not only about the HIV pandemic itself, but also about sexuality, gender and their social construction.

Many of us, from the early days of the pandemic, were caught up in a sometimes manic race, just to stay ahead of the ‘game’. Some of us tried to combine our action and reflection in the light of human experience, with growth in knowledge, and principles drawn from the sometimes deliberately obscured treasure-houses of our faith traditions. We tried to allow theology and social analysis in a time of AIDS to speak to us of ultimate meaning for people living with HIV, and to provide detailed pictures of particular population groups and their needs. Beyond this, theology in a time of AIDS also speaks to us of God; who, why, how, and what is God in the midst of this reality? (3) Social analysis prompts us to understand the mechanics of systems and structures and how these impact upon individual human beings and their communities.(4)

Paradoxes remain between the individualisation of HIV, on the one hand, and a propensity to scapegoat whole populations and minorities on the other. Skewed concepts of judgement and justice contribute to the lack of a structural understanding of sex and sexuality, particularly in faith leadership, and how this contributes to ever-extending demonising and victimising within our communities. Without such awareness, pastoral ministries, whether towards those living with HIV, or those serving the needs of women and lesbian and gay people, are in danger of creating a pastorale of dependency, rather than of empowerment or liberation.

“ ‘I’d shoot my son if he had AIDS’ says Vicar” was a tabloid headline in 1986. “Better dead than gay,” later to be the title of a Channel 4 documentary, was the comment of one conservative lay-preacher on his son who had committed suicide, tormented by the strain of parental rejection over his sexual orientation. These, and other headlines, were the logical outcomes of some early responses to AIDS here in the UK, in the mid-80’s. Although the “God’s punishment” brigade never achieved much influence upon mainstream faith leadership, some of the early statements were highly moralistic. One by one, hierarchical leaders rejected any suggestion that AIDS was God’s punishment, but few statements were able to stop short at that.(5) The early safer-sex messages and the promotion of condom-use in government advertising were judged by many as promoting promiscuity, rather than preventing further infection, or death. ‘But’ became a favourite concluding word!

What emerged was a perception that if individuals could be shown that their infection was the result of their own personal behaviour, rather than some spurious divine intervention, then people would turn from their so-called ‘promiscuous’ life styles, and the epidemic would cease. In religious terms, all people had to do was to turn away from sin! In those earlier days the awareness of a global pandemic was hardly recognised, so there developed, particularly in the United States, a labelling process resulting in scapegoated populations of all the ‘H’s’ – homosexuals, heroin-injectors, Haitians, haemophiliacs.

Preoccupation with so-called ‘risk-groups’ engendered an attitude that as long as someone was not a member of these populations, they were safe. This ignored the reality that HIV was a matter of behaviour and not of one’s sexual identity, nor ethnic background. Clearly, anyone who did not practise safer sexual or drug use behaviour, or who in health care settings did not adopt safer working practices such as not re-using un-sterilised equipment, was at risk of HIV and other infectious disease
transmission.

These early tensions in public health services between individual-targeted strategies and population group prevention programmes reveal, in retrospect, the need to understand the HIV pandemic as a ‘both/and’ phenomenon. There is clearly a need for behaviour change, but in many of the risk situations, it takes ‘two to tango’, so sexual and other negotiation skills are needed. Belief in one’s own adherence to partner-fidelity does not render one immune to the effects of another partner’s sexual behaviour outside the primary relationship.

As the impact of the HIV pandemic became clearer, so it became more apparent that comprehensive populations, and not solely minority groups or vulnerable individuals, were subject to systemic pressures that added to their likelihood to nurture HIV and other epidemics. Such structural aspects would also
need to be taken into account, in classical moral theology debates as judgements came to be reached about the extent of personal freedom exercised in behavioural choices.

The social analysis of many African countries exposed the enormity of the social construction of HIV, the effects of which could be tempered, but not resolved by individual or minority group behaviour modification alone. There is obviously a need to deal with root causes as well as symptomatic interventions. The “problem tree”, developed by CAFOD, is a useful model to portray this. The branches and leaves ( sickness, death, grief, poverty, human rights derelictions, drop in life-expectancy, lost skills of working generations and economic impact, orphans, lack of education, drain on health resources, gender inequalities) of the HIV/AIDS tree are the first things we respond to in mitigating the impact.

We see the routes of HIV transmission on the ground through blood, sexual risk behaviour, and mother to infant. Reducing the risk at the surface level, we go beneath the surface, even deeper to the roots, attempting to decrease the vulnerability, and we see more hidden concerns around migration, refugees, sexual violence, sex work/bartering, including human trafficking, ignorance, peer/social pressure, personal poverty, substance misuse, lack of legal and human rights structures, political instability and civil wars, silence/complicity of religious and cultural structures, local and global poverty impact, deeper gender inequalities (6)

In the past, Catholic responses to the challenges of HIV have been stereotyped as solely concerned with not compromising the Church’s teaching on artificial birth control. The neat separation of controversial areas of prevention from support and care has enabled Catholic agencies to provide around 25% of treatment and care services globally. The traditional Catholic moral theology principle, that matters of personal conscientious decision remain within the “internal forum,” has meant that Catholic workers can legitimately refrain from direct intervention in issues of personal prevention. Some might see this as no more than, “Don’t ask, don’t tell!”

The “AIDS as God’s punishment” argument was only exceptionally heard in the Catholic context. In more conservative Protestant climates the vengeful God was as loudly proclaimed in the early days of the pandemic, as the “No condoms at any price!” chorus. The primacy of individual judgement and conscience, and the increasing acceptance of artificial contraception, meant that little was heard from mainstream Protestant and Anglican Churches on prevention issues. More recently, the harder edge of evangelical fringe Christianity has moved away from a vision of a punishing God, to urging believers that if only they believed more strongly in Jesus Christ as their personal Saviour, they would not have become infected with HIV, nor would they require currently available treatments. Proof of their trust in God will be found in throwing away their prescriptions, or risking unprotected sexual intercourse.

Growing numbers of theologians are re-doing their theology in the light of their increasing reflection upon the lives and choices of people living with HIV. (7) In turn, the experience of faith-based social care and development agencies such as Christian AID, CAFOD and Caritas, Tear Fund & World Vision, alongside the considered advice offered by theologians, are affecting the hitherto rigidity of some
religious institutions.(8)

Who is the God present to, and discovered by people living with HIV? In lives of risk and vulnerability,
 f resurgence and new hope, the God who claims people’s faith is a God who risks being in covenant with a gathered, conflicted, topsy-turvy, consistently messy people – not a God of the squeaky-clean! God’s divine strategy of giving priority to the poor prompts believers to open up in faith, hope and love in a praxis marked by the biblical values and virtues of truth/truthfulness, freedom/liberation, justice/doing justice, shalom/peace-making.

The Irish theologian, Enda McDonagh has described this reign of God as an account of the risk of God; he says:

“The disciples of Jesus are called to follow his risk-laden example in seeking the sick and the poor, the stigmatised and excluded. They have to be prepared to be stigmatised and excluded themselves while challenging some of the orthodoxies of their time. Healing or plucking ears of corn on the Sabbath may be near blasphemy to certain ‘orthodox’ leaders, but they illustrate the priorities of the reign of God: people before rules, the needs of the sick and the hungry before the concerns of the comfortable and powerful. In the face of HIV/AIDS Christians must be prepared to take risks. This is the way to ensure that God’s reign is emerging among us.” (9)

The individualisation of people living with HIV led to such an emphasis on personal culpability and victimisation that many religious bodies could only relate to such people insofar as they accepted a passive victim role, or as recipients of the Church’s healing ministry. As they ‘came out’ in their sero-positivity or their sexual orientation they were either ignored, silenced, or acknowledged in new ways within the faith community. More systemic frameworks are slowly being seen as helpful tools to explore ways forward.

In a Catholic context, theologians such as James Alison, Mary Hunt, Mark Jordan, Kevin Kelly, Gareth Moore, and social historians like John Boswell and Alan Bray, have engaged positively with a combination of social construction theories, the unveiling of obscured historical realities, and biblical and literary analysis. As Kevin Kelly remarks:

“Our sexuality as a human phenomenon, does not exist outside of history, but can actually be influenced, modified and even changed through the interplay of various cultural variables in the course of history. If this is true, it would seem to follow that our sexual ethics needs to be open to modification and reappraisal to take account of significant changes occurring in our sexuality … The application of the notion of social construction to human sexuality might seem to be diametrically opposed to a natural law approach to morality. In fact, very rich insights can be drawn from combining the enriched contemporary understanding of natural law with the notion of social construction. The theological concept of natural law provides a very enlightening interpretative lens for our examination of the human reality which we have been helped to understand better through the notion of social construction.”(10)

Debates within the Roman Catholic Church around HIV prevention have shown that development of teaching is possible. There is a growing global consensus amongst senior Cardinals, including the present and previous Pope, respected theological advisors - even those of a conservative ilk – that the promotion of life, the values of social cohesion, and the needs of healthy communities and individuals can be served by the use of effective means of HIV prevention, including the use of condoms in appropriate circumstances.

Within the Roman Church, there has been great confusion amongst the hierarchy over its responses to these two major, but distinct areas of controversy in terms of sexual ethics: HIV and homosexuality. One contributory factor, shared I suspect with other faith leadership, is the lack of a serious understanding of systems theory, particularly insofar as this might impact upon both personal and corporate realities in our Churches.

I’m reminded of an interview, given by Rowan Williams shortly after his appointment as Archbishop of Canterbury, when he confessed that he was not a strategist! Schooled, as many of this generation of leadership is, in a rightly personalist approach to controversial pastoral matters, save for a few exceptions, our pastors and teachers have been unable to embrace an approach to pastoral strategy that moved beyond something done to individuals, a pastorale of dependency, to enabling new systems of pastoral empowerment and liberation to flourish. Such models can cause radical upheaval, bringing a new kind of church into being. When these have been taken seriously, new dynamics of faith, action, mission and worship are created, sometimes frightening the powers that be that the foundations are quaking; truly the Church from below!

Another aspect of this confusion is as a result of systemic dishonesty, a concrete symptom of structural sin in the Church. At the heart of the matter is a Gospel imperative for the whole Church to respond pastorally in a way which respects the honestly lived experience of those who are the focus of attention - people living with HIV, those affected and those who care for them; and lesbian and gay people, and people with HIV, their parents and families. Our hierarchies often appear to have a vested interest in maintaining a private, individually-focussed pastoral strategy. To begin to recognise a more strategic and communitarian approach, closer to the models of Church portrayed in the Acts of the Apostles, is to tread dangerous paths.

Yet the social reality of people living with HIV has in many places been changed due to the impact of more effective treatments. The increasing social and legal recognition of same sex partnerships, of anti-discrimination legislation relating to access to services and the fostering and adoption of children, have accorded lesbian and gay people a status in society which goes beyond the privacy of sexual relationships. No longer can faith communities and their leadership consider these issues as private or public, as the whim takes them. Their pastoral practices, as well as doctrinal, liturgical and ministerial responses, must take into account the social as well as the personal dignity of those who are sisters and brothers in the Body of Christ, the People of God.

The major crisis for the Church, as well as other faith groups, as they face the 3rd Millennium is a crisis of truth. Underneath all the mishandling of sexual abuse within the Church, and its often consonant abuse of power, is a failure to recognise the truth of the reality facing it, or to actively disguise it, since the dysfunctional abuse of power can be seen, at times, to go to the heart of the institution. Much of the failure to develop an adequate and inclusive sexual theology is the refusal to accept the truths of contemporary insights from human sciences as acceptable tools which can serve theological reflection on what is, in the words of the late Cardinal Hume, the “created design” of lesbian and gay people and our being gift to each other, to the Church and the world.(11) It looks as if the new Bishop of Rome, Francis, is trying to face up to some of this.

The failure to respond holistically to the pandemic of HIV and AIDS is the reluctance to accept the intertwining of complex personal and social realities of those who live with HIV, and to be silent, or complicit in promoting misinformation, about the demonstrable efficacy of HIV prevention methods and treatments. Although quick to challenge secular organisations dealing with reproductive and sexual health issues, or the rights of sexual minorities, as driven by negative ideologies, the Church’s search for truth is often dangerously obscured by a drive for expediency, and ideology dressed up as doctrine. Let those without ideology cast the first stone!

In all these debates and in the balance between orthodoxy - right belief - and orthopraxis - right action - there has to be a fundamental option for truth since, in the end, it is the truth that will set us all free. (12)

(1) Cf. Kelly, Kevin, New Directions in Sexual Ethics: Moral Theology & the Challenge of AIDS, Cassell, London 1998; ed. Keenan SJ, James F, Catholic Ethicists on HIV/AIDS Prevention, Continuum, London 2000; Smith, Ann & McDonagh, Enda, The Reality of HIV/AIDS, CAFOD/Trocaire/Veritas, Dublin 2003. (2) A comprehensive picture is painted by Stephen Lewis, UN Special Envoy for HIV/AIDS, in the 2005

Massey Lectures, Race Against Time, broadcast on CBC and published by House of Anansi Press Inc. Toronto, Canada.

(3) McDonagh, Enda, Professor of Moral Theology, St. Patrick’s College, Maynooth, Theology in a Time of AIDS, Irish Theological Quarterly, Vol.60, No.2 1994.

(4) Social analysis as an academic approach studies a particular social situation in a detached, often abstract way, dissecting its elements for the purpose of understanding. Social analysis as a tool of pastoral action looks at the reality from an involved, historically committed stance, discerning the situation for the purpose of action. Closely linked to Paolo Freire’s methodology the ‘pastoral cycle’ of experience > social analysis > theological reflection > pastoral planning > evaluation is often seen as the practical community application of liberation theologies.
Cf. Centre of Concern, Washington DC: www.coc.org

(5) Pendergast, Martin, Christian Reaction to HIV in Britain, ONE for Christian Renewal Publications 1990.

(6) op. cit. Smith, Ann, The Reality of HIV/AIDS, Chapter 3: Towards a Comprehensive Programmatic Response.

(7) op. cit. Kelly, Kevin; Clifford, Paula, Theology & the HIV/AIDS epidemic, Christian Aid, August 2004; Fuller SJ, Jon & Keenan SJ, James F., Educating in a Time of HIV/AIDS, in Opening Up - Speaking Out in the Church, ed. Julian Filochowski & Peter Stanford, Darton, Longman & Todd, London 2005.

(8) cf. www.cafod.org.uk; www.christian-aid.org.uk ; www.caritas.org put ‘HIV’ in search;
www.e-alliance.ch (Ecumenical Advocacy Alliance)

(9) op. cit. McDonagh, Enda, The Reality of HIV/AIDS, Chapter 2: HIV/AIDS in a Christian Perspective.

(10) op. cit. Kelly, Kevin, New Directions in Sexual Ethics, Chapter 2: Social Construction & Natural Law.

(11) Hume, Cardinal Basil, A Note on the Teaching of the Catholic Church concerning Homosexual People, April 1997 (revised from 1993) : “ In all the circumstances and situations of life, God calls each person, whatever his or her sexual orientation to fulfil that part of his created design which only that person can fulfil.”

(12) Jon Sobrino SJ is one of the key theologians who has described the effects of structural sin within society and Church; cf. his essay, Getting Real about the Option for the Poor: Depth & Diversity, in Opening Up - Speaking Out in the Church, op. cit.