THEOLOGICAL CHALLENGES POSED BY THE GLOBAL PANDEMIC OF HIV/AIDS 
A Reflection by Rev. Robert J. Vitillo, of Caritas Internationalis,
with the Theological Study Group on HIV/AIDS, Boston College
23 March 1994.
First of all, I would like to thank Fr. Jon Fuller and all of you for the kind invitation to share concerns and reflections on the global pandemic of HIV/AIDS with you this afternoon. I am keenly aware that I come as a stranger to your group and thus must labor under several disadvantages -- for both you and me. I have not been present for any of your previous discussions and thus apologize if I raise issues which you have previously discussed, or better yet have even resolved! Although I majored in theology during my undergraduate studies and then pursued graduate studies in the field before ordination, I am not currently working in the field and thus must beg your indulgence for any inaccurate or outdated terminology or concepts which I might propose. With those reservations aside, however, I feel deeply honored and privileged to share with you the questions, concerns, frustrations, and expectations related to theological reflection which have been relayed to me by persons from various parts of the world who are either living with this condition or who are working on a day-to-day basis in providing HIV/AIDS education and advocacy or care to those affected by the pandemic.
Perhaps I might begin by offering a brief word about my organization’s involvement in the field of HIV/AIDS. The organization for which I work is Caritas Internationalis, which is a confederation of 125 national member organizations which have been given the mandate by the Episcopal Conference or national hierarchy to coordinate the social service and development work of the Catholic Church in their respective countries. At a General Assembly held in Rome in 1987, the member organizations first addressed the global implications of HIV/AIDS in a plenary discussion; the reactions of the participants might best be described as alarmed and confused. Some denied that AIDS was a problem even in countries where the impact was quite evident. Others expressed encountering difficulties with Church authorities by entering into AIDS education or service. Still others could not see how church-related sociopastoral organizations could avoid entering such work. At the end of the discussion, there seemed to be a resolute -- if somewhat uneasy -- consensus among the Caritas member organizations that HIV/AIDS should be selected as one of the priority themes of reflection and action for the Confederation during its 1987-1988 mandate. This same resolution was reaffirmed in a much more positive manner at the 1991 Caritas Internationalis General Assembly.
Since 1987, I am pleased to report that Caritas Internationalis has attempted to mobilize a non-judgemental and compassionate service response to the challenges posed by this pandemic in the following manner.
by sponsoring educational seminars on the global, regional and national levels (primary target audiences are church leaders -- bishops, clergy, religious men and women, lay catechists, and those engaged in church-related health and social service activities;
by establishing a Working Group of Experts who could provide consultation and guidance to those interested in organizing church-related HIV/AIDS services in various parts of the world. I am happy to report here that Fr. Jon Fuller has been serving as the North American representative on the Working Groups since 1991.
By seeking funding and professional expertise to support some 12 HIV/AIDS projects in Africa, Asia, Eastern and Central Europe, Latin America and the Pacific.
By organising for the exchange of experiences among those actively engaged in such ministry as well as those who are contemplating entry into the field.
The reflections which I would like to share with you this afternoon might be divided into three main areas.
Moral/Ethical Issues Related to HIV/AIDS
Fundamental Issues
Ecclesiological Issues
1. Moral/Ethical Issues Related to HIV/AIDS
Rather than launching directly into some of the well-debated ethical issues related to prevention, I would prefer to begin with those related to distributive justice, since I believe that they underlie much of our reflection and action in this field. I am frequently challenged by colleagues in the Caritas network who ask why we should expend so much time and so many resources to respond to HIV/AIDS when the world continues to be plagued by a myriad of other health and development crises. Thus the first distributive justice question for me is whether this pandemic warrants so much attention, concern and activity.
While I do not wish in any way to detract from other health-related, social and development endeavors, I do believe that HIV/AIDS is rather unique in its nature. Some reasons underlying my belief are the following:
HIV does not have a well-defined geographically limited spread as do many other epidemics. It has already spread to every corner of the earth, to every age group, every level of society and to persons of all sexual orientations.
HIV is not self-exhausting as are other epidemics; it involves an incubation period of ten to fifteen years or more during which the infected person neither notices or reveals any evidence of disease and yet remains capable of transmitting the virus to others;
The transmission of HIV involves substances and activities which are vital to human existence – i.e., blood and sexual intercourse.
The World Health Organization estimates regarding the present-day epidemiological evolution of this disease are already quite convincing:
more than 14.5 million people worldwide are infected with HIV;
some 3 million people have already advanced to the stage of serious illness, or AIDS;
some 5 out of every 11 HIV-infected persons in the world are women;
more than 1 million babies have been infected with the virus;
the epidemic is presently spreading in South and Southeast Asia at a pace which is similar to that which took place in sub-Saharan Africa during the 1980s.
The experts tell us that the numbers of persons infected by HIV will continue to grow at a frightening rate, maybe in the range of 30 to 110 million by the year 2000, and may even reach 1 billion within the first decades of the next millennium. The number of persons living with AIDS is projected at 10 to 24 million by 2000. By that same year, it is expected that at least 10 million children will be orphaned as a result of AIDS deaths of one or both of their parents and another 10 million children will themselves be infected by HIV.
Perhaps the most compelling statistics which I have recently seen relate to the number of life years saved by preventing the occurrence of one single case of the following diseases:
DISCOUNTED HEALTHY LIFE YEARS SAVED PER CASE, VARIOUS DISEASES, AFRICA	
DISEASE	LIFE YEARS SAVED	
Gastroenteritis	1.4	
Pneumonia (adults)	2.0	
Malaria	3.2	
Syphilis	3.8	
Measles	5.0	
Tuberculosis	7.1	
Pneumonia (children)	11.2	
HIV infection	19.2	
Neonatal Tetanus	22.7	
Source: Mead Over and Peter Piot (1992), “HIV Infection and Sexually Transmitted Diseases” in D. Jamison and H. Moseley (eds.) Disease, Control Priorities in Developing Countries: New York, Oxford University Press.	
These statistics do not even begin to tell the story of the “Hidden Costs of AIDS” which will pose unheralded challenges to the Church’s diaconal apostolate. These include the following:
the need to restabilize the economic, health and social support base at the local and even the national levels in many developing countries where large numbers of young and middle-aged adults (i.e., the most economically productive members of the society) are becoming ill and dying of AIDS;
the care of elderly persons who are suddenly surviving their adult children and thus unable to rely on the traditional systems of family care;
the nurturing and education of thousands of children whose parents have either died or have become severely incapacitated because of AIDS;
Against such a sobering scenario, I would like to raise the following distributive justice concerns which are, in my opinion, begging for serious theological reflection.
The World Health Organization estimates that key HIV prevention programs could be implemented successfully in developing countries for between $1.5 billion and 2.9 billion a year. This represents only 1/20 of the amount spent on Operation Desert Storm which cost the sum of $49 billion. I recall a fair amount of theological debate on whether Desert Storm conformed to the Just War Guidelines; but I have seen very little theological attention being focused on the equitable share of government and private resources which should be directed to HIV prevention.
When taking into account the meager funds which are expended on HIV/AIDS services, we are confronted once again with many inequities. Thus we note that, during 1992, 80% of HIV-infected people live in developing countries, while 95% of the (US) $7 billion spent last year on AIDS education, care and research was expended in the industrialized world.
Although four developing countries have been called upon to offer subjects for the first large-scale human trials of potential HIV vaccines (i.e., Brazil, Rwanda, Thailand, and Uganda), there is no guarantee that the residents of these countries will be availed of such vaccines on a widespread and affordable basis once they have been perfected. Thus I will never forget the haunting challenge posed by Uganda’s Minister of Health at the 1992 International Conference on AIDS which was held in Amsterdam:
The people of Uganda are offering themselves as subjects in the vaccine trials for the good of all humanity; do not forget us when the vaccines arrive in the marketplace!	
I do not wish to leave the impression that these distributive justice dilemmas are restricted to the macro level. Allow me to offer some very specific incidents in which my Caritas colleagues have been involved:
Our network has been supplying rapid HIV-antibody test supplies and equipment to mostly rural-based, church-related health services which are called upon to administer blood or blood products but have not benefited from the testing facilities provided by governments or the World Health Organization, which are often concentrated in national and provincial capitals and never arrive in the more isolated areas of developing countries. We had negotiated a special rate in the more isolated areas of developing countries. We had negotiated a special rate with one prominent pharmaceutical company for HIV-1 Antibody Test Kits. When that same company developed a test which could detect both HIV-1 and HIV-2 antibodies, they raised their price from $1 to $3 per test kit. We approached the company and explained that the new price range made it extremely difficult for us to purchase large supplies for our partners in the developing world. The response which we received from company officials was that the test had been developed for the residents of Northern, or rich, countries, not for those in the South.
Last week I visited an AIDS Counseling and Service Center in Ethiopia. There I was shown the empty medicine cabinets by the nurses; they have been unable to obtain desperately needed T.B. medication for their clients. They have only a five-week supply left and know that, if they begin new patients on this therapy today, they may not have enough medication left to assure a full course of treatment. All their appeals to governmental and private funding sources have so far fallen on deaf ears.
There are indeed some other ethical/moral issues which I feel compelled to mention. The first set of such issues relate to PERSISTENT AND WIDESPREAD DISCRIMINATION AGAINST PERSONS LIVING WITH HIV/AIDS. In almost every country which I have visited in recent years, such discrimination is rampant -- even in church-based pastoral, health and social services. One bishop asked me in full assembly with his brother bishops from an entire continental region how he could instruct his priests to “spot” a person with AIDS so that they could avoid coming into contact with such persons. I cannot adequately describe the disappointment of laypersons and religious alike, on almost every continent, with the clergy who refuse to visit or attend to the sacramental needs of persons living with the disease. Some pastors have even ostracized the families of such persons and of others in the community who are considered “sinful.” At times, priests have forced persons living with AIDS to publicly disclose their “sins” or to pay special taxes in order to remain as members of the local parish community and thus to qualify for a Christian burial.
The experiences in this area do not always remain negative. I recall specifically the medical director of a well-respected Catholic hospital in Southeast Asia who steadfastly refused to admit patients suffering with AIDS. After attending a Caritas-sponsored HIV/AIDS seminar and after being confronted with this policy, on both medical and ethical grounds, he not only reversed his previous decisions but also began a comprehensive HIV/AIDS training program for his entire staff.
The main challenge I wish to pose here is for theologians to link HIV/AIDS discrimination issues with other struggles for justice and with necessary condemnations of discrimination in other areas of social life. The proof of such a need lies in the fact that the very members of society who are most subjected to other structural injustices in society are the most vulnerable to the spread of the HIV/AIDS virus. Thus we see that the pandemic is most disseminated among the poorest and most marginalized in society. We know, for example, that women (especially very young women) are more biologically vulnerable to contacting HIV, have less control over their own sexual health and activity as well as over the sexual activity of their parents, and are often blamed as “vectors of HIV” even when the entry of the virus into the family circle may have indeed come from the marital infidelity of their husbands. When I have approached certain women theologians in the past with regard to a request to reflect on these HIV-related issues which are so fundamental to the survival of women in present-day society, I have often been rebuffed with the excuse that they are too busy with the struggle for justice and equality.
Another ethical issue which I am sure is not unfamiliar to you relates to HIV prevention education and specifically focuses on information related to the use of the condom with sexual activity (especially when one partner is HIV-infected and the other is not) and to the “clean needle” campaign with regard to injecting drug use. My personal opinion is that too much theological energy has already been dedicated to this issue; my experience in the field tells me, however, that many church-related service workers are still searching for accurate, practical and reality-based debate on this topic.
I cannot emphasize enough the need for accurate information on which to base our ethical discussions. There are indeed many persistent myths related to HIV prevention. Time and again, I have met religious leaders who are convinced that condoms (even when properly and consistently used) are not effective in preventing the spread of HIV, even though scientific evidence has proved this premise wrong.
There is also the myth that information about preventive techniques, especially among young people, will simply encourage early sexual activity or injecting drug use. Once again, the scientific evidence proves this assertion wrong. Perhaps the most compelling evidence in this regard was presented at the 1993 International Conference on AIDS in Berlin which reported studies demonstrated that well-designed school education about safer sex leads to more responsible sex, a delay in first intercourse, and fewer teenage pregnancies. Dr. Anke Erhardt (Psychiatric Institute, New York), for example, reported that age at first intercourse is similar in Europe and USA but, because sex education in European countries is better than in the USA, the rates of teenage pregnancy are dramatically different: the UK rate is less than half that of USA, and the Netherlands is ten times lower than in USA.
Here I must insist that the theological discussions need to be reality-based. In one seminar which I conducted in Asia, a very pious religious sister maintained that if she were married and her husband were infected with HIV there would be no question of condom use because, if her husband really loved her, he would not want to have sex with her. A married woman in the audience felt compelled to disagree: “If my husband were infected with HIV, we would need to continue our sexual relationship in order to offer each other the mutual support which we would both so desperately need!”
Finally, there is a need for practically-oriented ethical reflection on prevention. I recently visited a country which is just emerging from a 35-year-long and bitter struggle for independence from its neighbor to the South. Many of the returning and recently deployed military (which included both men and women) are HIV-infected and are beginning to develop the systems of AIDS. I was informed by one church worker there that the religious in the country had written to the bishops and insisted that they could no longer stand idly by and watch people die of AIDS. They begged the bishops to offer some ethical guidelines for both care and prevention. The response of the bishops was to send a canon lawyer to a meeting of the Conference of Religious. This canonist cited the Code of Canon Law but revealed no practical knowledge of the situations faced by persons living with HIV/AIDS, by their loved ones, or by those who wish to be of service in response to this pandemic.
The last ethical issue which I find especially delicate but necessary to mention involved the need to DENOUNCE SEXUAL ABUSE WHICH HAS ARISEN AS A SPECIFIC RESULT OF HIV/AIDS. In many parts of the world, men have decreased their reliance on commercial sex workers because of their fear of contracting HIV from such persons (no one ever seems ready to admit that many commercial sex workers are themselves infected by their clients). As a result of this widespread fear, many men (and some women) have turned to young (and therefore presumably uninfected) girls (and boys) for sexual favors. Religious women have also been targeted by such men, especially by clergy who may have previously frequented prostitutes. I myself have heard the tragic stories of religious women who were forced to have sex with the local priest or with a spiritual counselor who insisted that this activity was “good” for the both of them. Frequently, attempts to raise these issues with local and international Church authorities have met with deaf ears. In North America and in some parts of Europe, our Church is already reeling under the pedophilia scandals. How long will it take for this same institutional Church to become sensitive to these new abuses which are resulting from the pandemic?
2. FUNDAMENTAL ISSUES
I am convinced that the pandemic of HIV/AIDS will force theologians to grapple more seriously with the fundamental theological premises related to human nature, and, more specifically, related to human sexuality. Notice that I have placed the need for theological reflection related to sexuality within the fundamental rather than the moral order. It seems to me that theologians have not yet faced the daunting task of elaborating a substantive theology of human sexuality as a creation of God who willed this to be such a strong, dominant, and constitutive element of human nature. Nor have we sufficiently considered how God’s grace has elevated the totality of the human person (including his/her sexuality) to a level which is different from the rest of animal or plant life.
All too often, I have met Christians -- clergy, religious and laypersons -- who have been scarred by our Church’s refusal to seriously acknowledge the sexual side of their being. I was greatly impressed by the courage and stamina of one Italian woman religious who worked for many years in Mozambique. She feared neither the government military nor the rebels and confronted them openly when she noticed any unjust treatment of the civilian population. When this same woman participated in a national-level seminar on HIV/AIDS, however, she became visibly shaken and uncomfortable each time there was any discussion of sexuality. After some open and frank debate within the group, she finally admitted that she had long harbored the idea that any sexual behavior -- even among married couples -- was somehow selfish and base and shared her previous belief that only celibates could fully follow the Lord. She thanked the group for assisting her to develop a more mature and integrated vision of her own life and sexuality.
Too long have we assigned sexuality to a deep, dark secret in our Church. One Latin American bishop stated publicly during a HIV/AIDS seminar which I attended that there were only two things which he refused to discuss with his priests -- their financial condition and their sexual behavior (he did not use such a refined term!). I believe that it is indeed time to discuss sexuality with priests, religious and laypersons alike -- not in order to denigrate the value and gifts and choices of celibacy or of faithfulness in marriage, but rather to assure a more healthy and integrated personal life no matter what one’s particular vocation in life might be.
Another challenge for fundamental theologians is for them to assist the citizens of the world to delve into the meaning, at this particular time in our world history, of this pandemic and of the personal suffering which it entails. Most unfortunately, some church leaders (including some among the Catholic hierarchy) have claimed that this pandemic is God’s punishment on those who are considered to be unnatural, or abnormal, or sinful. Those church leaders may have been small in number, but their voices have been heard far and wide. Some still persist in this negative message about God’s relationship with human persons. Last year, I traveled to an Asian country to facilitate a workshop for the bishops there during one of their regular Episcopal conference meetings. Upon my arrival, I was pursued by a prominent archbishop who began to question me about whether I believed that AIDS could be a punishment from God for those who are promiscuous. The archbishop was not satisfied with my negative response and continued the same line of questioning during a plenary presentation the next morning. “Have you not read the Old Testament where God does such things?” he asked. I replied that I had indeed read the Old Testament but also had read and reflected on the New Testament in which Jesus brought a message of acceptance and forgiveness. The archbishop was not one to concede and thus continued to stress his point that promiscuous people deserved to be punished. Finally, I reminded him that many people who in no way could be considered promiscuous also had contracted HIV and I simply could not put my faith and hope in a capricious, vindictive God. During the coffee break, many of his fellow bishops complimented me for my response, but none of them had been willing to support me during the discussion which had been held earlier.
There are indeed many persons living with HIV/AIDS and those who care for them who have found deep meaning and redemption in the suffering associated with this disease. Many others, however, are still searching and would benefit immensely from serious theological reflection in this regard.
3. ECCLESIOLOGICAL ISSUES. 
The final area of concern which I would like to pose here relates to the nature and mission of the Church. I believe that the pandemic of HIV/AIDS is forcing us to clarify once again the vision of our Church. Throughout the world, I have observed the tendency to restrict membership in the Church to those who might be considered sufficiently “orthodox,” “loyal,” etc. Persons living with HIV/AIDS and their loved ones are begging to be accepted and treated as full members of the Church in spite of the fact that they may not always have been fully active or faithful to Church teachings and practices. During a presentation which I gave several years ago in a Latin American country, I reminded the audience which was filled with priests, religious, seminarians and lay leaders that Jesus went in search of the marginalized and the outcasts in his society -- even of the prostitutes. A moral theology professor at the national seminary offered a response to my talk. He pointed out that I was technically correct in recalling such actions of Jesus. He quickly added, however, that seminarians in the country need not search for such ministerial opportunities among prostitutes; this was work better left to nuns and laypersons. Even more disturbing are the frequent questions of gay men living with AIDS about why the church has no room for them -- why the Church has to wait until they are dying to offer them gestures of love and care. I have frequently been told by medical staff in some countries of the South where polygamy might be practiced that priests often insist that men who are at the point of death as a result of AIDS-related illnesses must first abandon all their wives -- but one -- before they could receive any sacraments or spiritual comfort. There does indeed seem to be an ongoing need for theologians to pursue reflection on the truly “Catholic” universal nature of the church.
Once again I must point out that many lay and religious workers have organized some excellent outreach to marginalized persons living with HIV/AIDS and have engaged them once again as full members of the Christian community. They desperately need the support of others -- and especially of theologians -- to affirm and support such work. A religious sister in Lebanon recently recounted to me a special experience which points out the need for such encouragement. She came to know a homeless man who was suffering with AIDS; after much struggle, she finally was able to arrange for his hospitalization so that some of his acute illnesses might be properly treated. During the time of his hospitalization, he expressed a great interest to learn more about the Church and to practice more deeply his newly revived faith. When the man was ready to be released from the hospital, he once again had no one to offer him appropriate shelter. The sister went to the local parish priest to ask his assistance in offering the man temporary shelter. The priest was certainly familiar with the man since the latter had lived outside the parish church for the past several years. The priest was making Communion hosts when the sister made her visit. She enthusiastically described the man’s physical and spiritual revival. Then she asked the priest to receive the man in the parish house for a short time to assure that he could receive decent food, be kept warm and be able to pursue some catechetical lessons. During the sister’s presentation, the priest continued to make his hosts without even looking up at the sister; he offered no response whatsoever. Finally, the sister pointed out: “You, Father, are making hosts which will soon become the Body of Christ; I am asking you also to receive into your house a man who wants once again to be integrated into the Body of Christ.” The priest never did respond, so the sister took the man into her own home.
CONCLUSION
As I conclude this presentation, I am conscious that I have raised many issues and concerns and have been able to offer few answers. I can only assure you of my solidarity as we struggle together to reflect on the theological implications of this new reality in our world. Several theologians have raised questions with me about whether they could be helpful in the face of such a disastrous pandemic. One theologian shared with me her doubts that anyone really wanted to hear from theologians. Another described himself as a member of an “endangered species” -- a moral theologian. I must tell you of the deep need and strong enthusiasm for theological reflection which is experienced by many persons living with HIV/AIDS and both those who offer HIV-related education and service.