For a life with dignity. The global threat of HIV/AIDS: possible courses of action for the Church

A Study by the Evangelical Church in Germany's Advisory Commission on Sustainable Development, EKD Texts 91, 2007 - Published by the Church Office of the Evangelical Church in Germany (EKD)

3. Challenges and areas for action

As was shown in Chapter 2, HIV/AIDS has become a global threat from which no country is safe. Although there is significant variation in the degree to which the individual countries presented in Chapter 2 are affected, the worldwide effects can now be felt everywhere.

3.1  The effects of HIV/AIDS

HIV/AIDS is not only a disease; it is also a complex social problem that has considerable impact on development in affected countries. The effects of HIV/AIDS threaten the economic, social and political stability of entire countries and regions and therefore also pose a global challenge.

HIV/AIDS is a disease linked to poverty. Its effects are particularly harsh for poor people and population groups in developing and industrialized countries. Poverty implies not only a lack of money, but also discrimination, lack of participation in political life, lack of access to resources (information, health care, education), the non-respect and violation of human rights and values, lack of prospects for the future, stigmatization and discrimination. All of these promote the spread of HIV/AIDS.

The chronic illness and deaths of people in their most productive years leads to a vicious circle: poverty leads to illness and illness aggravates the poverty. For private households in poor countries the direct costs of the disease (treatment and care) and the indirect costs resulting from the loss of income are enormous: in the final stages of the illness, AIDS devours the entire income resulting in acute indebtedness (10). The system of solidarity among the extended family that provides social security in poor countries is overstretched and in many places has already collapsed.

In sub-Saharan Africa, food security is being jeopardized by HIV/AIDS. HIV/AIDS is increasingly a contributing or aggravating factor in famine disasters. Here too there is a vicious circle at work: when people die, their knowledge is also lost, and less land is farmed as a result. When the yield is smaller, there is also less money available for health care, which can in turn lead to a loss of manpower.

Industry and the public sector are affected too. Many poor countries depend in key areas on a small number of highly qualified specialists. In the worst affected countries, large numbers of these well-educated people are dying.

In some countries for example more teachers are dying than are qualifying, thus restricting the educational opportunities of entire generations. For girls especially, this hampers their prospects of being independent in adulthood. This in turn leads to a deterioration in the health situation of further sectors of the population, as the health of families depends to a large extent on women's level of education.

Health systems in developing countries, weak in general, are being weakened further by the deaths of doctors and nurses, whilst at the same time the high number of patients with HIV and AIDS is producing an increase in demand.

The negative social and economic effects promote the continued spread of HIV/AIDS as a result of the increase in poverty and the vulnerability of entire population groups. This impedes sustainable development and frustrates the progress made so far. Communities and States are gradually being weakened by death, illness, the orphaning of children and the loss of informal and formal knowledge. The effects of AIDS on the economic and social structures of countries with low and middle incomes and high infection rates are catastrophic, but even in countries with lower HIV rates, the effects on some aspects of development are worrying. For example, it has been estimated that AIDS will diminish poverty reduction in Cambodia by 60% each year until 2015. In Eastern Europe and Russia, the epidemic is hampering the prospects for human development and economic growth.

HIV/AIDS therefore has serious consequences for the achievement of the Millennium Development Goals(*) set at the United Nations Millennium Summit in 2000(11). One of the goals that Heads of State and Government undertook to achieve by 2015 was to combat the HIV/AIDS epidemic. In the Least Developed Countries especially, it is unlikely that this goal will be achieved, as was indicated in the overview report issued by the Secretary-General of the United Nations at the beginning of 2005(12). As a result above all of the HIV/AIDS epidemic in Africa, the situation has in fact even deteriorated in comparison to 2000. HIV/AIDS is undermining the achievement of the other Millennium Development Goals (reduce poverty, reduce child mortality, improve access to education, promote gender equality(*), improve maternal health and combat the main infectious diseases). The further expansion of existing approaches to combating HIV/AIDS is above all being thwarted by the lack of health facilities and staff(13). In the resolutions of the United Nations World Summit of September 2005 the international community made a commitment to increase investment in improving the health systems in affected countries, in order to be able to achieve the Millennium Development Goals by 2015 after all. All the commitments set out in the HIV/AIDS declaration of commitment should also be fully implemented(14). Church authorities are also affected by HIV/AIDS in their daily work: clergymen are dying from HIV/AIDS; parishes are losing parishioners, are becoming poorer and are unable to care for the orphans left behind and for the chronically ill; and ministers can scarcely cope with the additional burden of pastoral care and funerals. Church authorities in Europe may not be so massively affected, but in their midst too there are people living and working with HIV/AIDS.

3.2  Women and gender equality

Although the equality of men and women has been set forth in law many times, there is still all around the world a great chasm between the political aim of equality and the reality in society. In development policy, attempts to counteract this trend currently take the form of "gender mainstreaming"(*), which means always thinking about gender issues with the aim of achieving equality. Gender(*) has established itself as the specialist term for sex-specific social roles including in the German-speaking world. Current research is proceeding on the basis that "gender" always encompasses social, cultural, political and biological components that are alterable.

The gender perspective also focuses our understanding of the AIDS issue. AIDS affects men and women, but not equally, in part due to differences with regard to power, privileges, access to resources etc. Most of the work of HIV/AIDS is done by women: unpaid care for the sick in the home; as mothers and grandmothers caring for orphans. Women undertake heavy labour in order to provide for themselves and their families in the face of poverty and the AIDS epidemic. Many women have managed by accepting their positive HIV status(*) to find new strength and power; they are active within communities and in networks of women living with HIV.

In many countries, women are dependent on men financially, legally and due to their lower level of education. It is not just biology, but also the oppression and lack of recognition of the rights and values of women that help explain why women are affected and burdened by HIV/AIDS disproportionately and in a variety of ways. These structural causes - in conjunction with men's exploitation of this situation and irresponsible behaviour - make women more vulnerable to HIV infection and to the effects of the epidemic. Their lack of self-determination also has consequences for their sexuality: in many countries women have very little or no say as to the form of and conditions under which sexual intercourse takes place.

In Africa young girls are at highest risk of becoming infected with HIV, as many are married to men who are significantly older than they are. Women and girls know little about sex; it is considered unbecoming to talk about it or to make decisions. In many places, the attitude persists that a woman's body "belongs" to her husband, that women do not have the right to say no within marriage (or sometimes even outside marriage). Talking about contraception or insisting that it be used is unthinkable for many women, as it is seen as a sign of lack of trust in the marriage and the non-fulfilment of the female role as child-bearer.

Women who are forced to sell themselves are particularly affected by stigmatization. Often they are blamed for "causing" AIDS. They are also shunned and discriminated against by and within some churches. Women experience worse stigmatization when they are they are HIV positive or are widowed by HIV/AIDS. They are accused of having brought HIV into the family. Women and girls are at greater risk of becoming infected through abuse and the use of violence. They experience violence through genital mutilation, domestic violence, sexual exploitation, forced prostitution and - often systematically - through rape in armed conflicts and wars.

In many countries up to 40% of drug addicts are women. Added to their risk of becoming infected through shared needles is the risk that they are exposed to as a result of the prostitution they use as a means of paying for their drug habit. In addition, women are often not included in HIV prevention and other programmes as a result of the still widespread assumption that drug addicts are male.

Women are made poorer than men when HIV/AIDS afflicts a family through illness and death, and are often robbed of their land and inheritance when they are widowed.

Until now, the primary or only aim in the debate about gender and HIV/AIDS has been to "strengthen and promote" women, which was supposed to change their tremendous vulnerability to HIV. However, it is also important to change the patriarchal structures that disadvantage women and given men power. We must try to effect change in the awareness and behaviour of men, so as not to expose women to the risk of HIV infection. This includes using condoms as well as refraining from promiscuity(*) and combating sexual violence.

Churches in Africa should consider these aspects in their AIDS work: "We shall remember, proclaim and act on the fact that the Lord our God, created humankind in his image. In his image, he created them male and female, he blessed them both and gave both of them leadership and resources in the earth; he made them one in Christ (Gen. 1:27 -29; Gal. 3:28 -29). We shall, therefore, denounce gender inequalities that lead boys and men to risky behaviour, domination and violence; that deny girls and women leadership, decision making powers and property ownership ."(15) .

In the resolutions of the United Nations World Summit of September 2005 the international community resolved to promote gender equality and eliminate pervasive gender discrimination. Member States undertook to actively promote the mainstreaming of gender into the design, implementation, monitoring and evaluation of policies and programmes in all political, economic and social spheres. States further undertook to strengthen the capabilities of the United Nations system in the area of gender. They declared that progress for women was progress for all.(16)

3.3  Treatment, care and prevention

3.3.1  Access to anti-retroviral medicines

For many years, whether people received life-extending antiretroviral treatment depended on whether they lived in a rich or a poor country and whether they could pay for the treatment. This meant that until recently people living in poor countries were very unlikely to have access to antiretroviral treatment.

Those in Africa had the worst chances. Until 2003 only 1% of all the people in Africa who needed antiretroviral medicines had access to them. In total, only 400,000 of the six million AIDS sufferers in countries with low and middle incomes received the necessary treatment with antiretroviral medicines.

The reasons for the low number of people receiving treatment were and are the pricing policies of the multinational drugs manufacturers as well as the international trade agreements that protect patents even for vital medicines, thus preventing competition with unpatented medicines, as well as lack of infrastructure and a poor level of education among heath workers (lack of investment, emigration of qualified staff).

Another reason for the lack of access to the life-saving treatment was the lack of commitment by Governments and civil society, including Churches. For years, national and international efforts to combat AIDS were predominantly focused on the prevention of HIV, as access to adequate treatment seemed unobtainable. That led to millions of deaths from AIDS which thus also weakened the HIV prevention efforts.

In recent years however, thanks to the commitment of many actors around the world, there has been a rethink. The lack of access to treatment of millions of HIV-positive people was taken up as an ethical challenge. At the same time, it was increasingly being recognized how important access to treatment was for maintaining the workforce, specialist knowledge, education and health as well as for good governance(*) and sustainable development in developing countries affected by HIV. It remains to be seen whether the change has been sufficient and how resilient it proves to be. In many countries, old prejudices have only been covered up out of necessity in the fight against AIDS, and not genuinely overturned.

International lobbying - including by Churches - and the competition generated by generic medicines(*) have prompted the manufacturers of antiretroviral medicines to substantially lower the price of these medicines for the poorest countries. However, this is still not enough for people in poor countries to receive adequate provision with medicines. In particular, the prices for the subsequent therapies that are needed in the event of resistance(*) to the initial therapy still run at several thousand Euros per year and are thus much too high. There is also a great need for treatment in the countries of Eastern Europe and the Russian Federation, which as European Union or middle-income countries do not benefit from the permitted discounts.

At the United Nations General Assembly at the end of 2003, HIV/AIDS was declared a "global health emergency". Through the Global Fund(*) and other financial instruments as well as the "3 by 5" initiative launched in 2003 by UNAIDS and the World Health Organization(17), it has been possible to increase the number of people receiving treatment for AIDS in countries with low and middle incomes to some two million at the end of 2006. This is a first step; the original goal of three million by the end of 2005 was not achieved. It did bring about a rapid increase in treatment, but the aim of treating six or even nine million people by 2010 can now only be achieved if further increased efforts are made.

In Africa most countries have in the meantime developed "national treatment plans". Demand for treatment generally far exceeds capacity, but the situation did improve significantly between 2003 and 2005. Whilst in 2003 only 1% of all AIDS sufferers had access to antiretroviral medicines, now 10% have the option of this life-saving treatment. All treatment initiatives include training health staff in prescribing and monitoring antiretroviral therapy and creating the infrastructure needed for widespread implementation of the programme. The experience of Brazil - as a middle-income country - shows that early "antiretroviral treatment for all" can reduce the costs of HIV/AIDS and stem the flow of new infections. Brazil's experience shows that the implementation of treatment should commence from the beginning of an epidemic. The consequential costs are higher for every person who is already ill or has died from HIV/AIDS. In the programmes conducted to date in developing countries, as in industrialized countries, it has been possible to achieve a considerable reduction in deaths from HIV/AIDS. In Uganda, for example, where more than a third of AIDS patients receive antiretroviral medicines, more than 90% of patients were still alive after 15 months of antiretroviral therapy, whereas without treatment only 50% of those ill with AIDS survived that long.

The improvements to health infrastructure carried out for the purposes of antiretroviral treatment also benefit the entire health sector, as they also help with prevention and the treatment of other diseases. In many African countries, up to 60% of national health care is provided by Churches. Consequently, church health facilities also play an important role in antiretroviral therapy. Churches in Kenya, Uganda, Zambia and India for example provide vital staff training, programme implementation and support for the community.

Failure to take medicines regularly or stopping therapy once it has been started can lead to  "resistance", which means the partial or complete ineffectiveness of the medication, which has serious consequences in terms of restricted treatment options. Under current conditions, when it is only the medicines for the initial therapy that have become relatively cheap, this is particularly difficult. The medicines for subsequent therapy and all newly developed antiretroviral medications are patented, which means no competition from cheaper generic versions. At the same time, pharmaceutical concerns are delaying significant price reductions. For that reason, Anti-AIDS activists, Churches and the German Action Alliance against AIDS (Aktionsbündnis gegen Aids) are calling for big pharmaceutical companies to voluntarily relinquish their patents in poor countries and to guarantee affordable prices for newly developed and not-yet-developed medicines. A swift and comprehensive expansion of the treatment programme would be a significant contribution to the fight against AIDS, which would also help to stop resistance from developing.

The active participation of people with HIV and AIDS, communities and civil society is crucial for the success of therapy programmes, as antiretroviral therapies present considerable challenges: the medicines must be taken for life, regularly and daily. People who receive treatment need the support of their families and communities. They need an explanation of the side effects and the specific modalities of the therapy. It is important to avoid a false sense of security. This "treatment literacy"(*) is promoted by many civil society organizations and in many places by Churches too.

Ensuring that disadvantaged population groups (women, children, people in rural areas, prostitutes, prisoners, drug addicts, homosexual men etc.), have access to antiretroviral therapy is a particular challenge. In order that treatment programmes do not worsen existing inequalities, treatment must be made possible for all sufferers. A sixth of all those who have died are children. Until now they have not been adequately considered in treatment programmes, because medicines are not sufficiently available in paediatric formulations and the price of such medicines is very high. Research into paediatric formulations of medicines proceeds only slowly and takes years because, due to the relatively low level of HIV-infected children in rich countries, there is not the profitable market for these medicines that would provide the stimulus for the private-sector development of paediatric formulations of medicines. However, such medicines are urgently needed in order to save the lives of millions of children. Between 2005 and 2006, the prices for paediatric formulations of medicines fell for the first time and now only cost around 12 cents per day, or 47 Euros a year(18).

Antiretroviral treatment is also crucial for HIV prevention. The reduction in infectiousness reduces the risk of an HIV transmission. Furthermore, as the effect of treatment is that AIDS is no longer a death sentence, this gives people the hope and strength to come to terms with HIV infection and tackle it openly. Accordingly, demand for HIV-tests soared in many treatment programmes, and there is a reduction in stigmatization. There are countless examples from church communities of people living with HIV and AIDS, who had been close to death but were now able to go back on with their lives thanks to antiretroviral medicines, giving moving accounts of their stories and thus reducing stigmatization.

One such example is the Masangane Project, which was launched in 1996 by the Moravian Church in South Africa's Eastern Cape Province and was implemented largely voluntarily by members of the community. Masangane initially focused on prevention work and on improving living conditions for young people. In 2002, Masangane introduced the antiretroviral therapy. This demonstrates that treatment with antiretroviral medicines is not something that has to be restricted to large health facilities, but can also be achieved under the responsibility of a community and in a rural area. It was possible to break the silence, and as a result it is possible for women, men and young people affected by HIV/AIDS today to talk openly to the community in Sunday church services about their lives and their experiences(19).

Overall, we have only made a start at providing the quantity and quality of this important treatment for AIDS to people in poor countries. The challenges described will in future require stronger commitment on the part of everybody involved.

3.3.2  Care

The introduction of antiretroviral combination therapy has resulted in the symptom-free stage of the disease in the lifetime of people with AIDS being significantly extended. It is AIDS sufferers in rich industrialized countries who currently benefit most from this medical advance, as for them combination therapy opens up much improved life prospects. Nonetheless, home, outpatient and in-patient care continues to play an important role in the care of people with HIV/AIDS.

In developing countries, only a fraction of those with HIV and AIDS receive essential medical care, psychosocial support and the nutritional help that is so often needed. Churches and church organizations play important roles with regard to the care of those affected by HIV. They care for the chronically ill in home-nursing programmes and for orphans and other at-risk children, who lack material and social support. The overwhelming share of the work has so far been done on a voluntary basis, unnoticed and without being explicitly valued and supported. This voluntary work is carried out almost exclusively by women. It includes the care work by mothers, wives and other females for sick family members, as well as the work done in the volunteer home care projects provided by many churches in Africa. This is generally not only not properly valued and supported (eg. through taking on the cost of materials), it is also often not appreciated how much time and energy women expend and is expected of them - time and energy that is taken away from their own (including financial) development.

In most African countries there is no alternative to such home care, as professional care would be unaffordable. This makes it all the more important for the voluntary work carried out in home care to be valued and for there to be more efforts to help the carers appropriately, such as by network building or a more equal division of care work between men and women.

Consideration of specific care situations requires a particularly sensitive approach, because it is care in particular areas of conflict:

• between the self-determination and heteronomy of those being cared for;
  
  
• between the life cultures of AIDS sufferers and carers;
  
  
• between short and long-term life planning;
  
  
• between phases of denial and acceptance of the disease;
  
  
• between carers and others involved in the care.

People with HIV/AIDS who have comprehensive knowledge about their disease and its treatment are less well adjusted, more self aware, more individual and more vulnerable than many other patients. This requires carers for example to consider the sexual orientation of the sufferer or the lifestyle of a drug addict. The willingness to face this challenge openly also offers a chance for an encounter that could lead to learning and a tolerant approach. It can lead to questioning and alteration of one's own care routine and the entire care concept.

3.3.3  HIV prevention

Treatment and prevention go hand in hand: they need one another and are mutually reinforcing. Thus, prevention must not be limited due to the cost of treatment and treatment must not be neglected at the expense of prevention. Both must be energetically strengthened and facilitated through the appropriate financial means. Only in this way will it be possible to reduce the estimated four million new infections and three million deaths each year.

Prevention measures are not universally in place and have not yet reached everybody. Achieving universal access to prevention, so that everybody has adequate information and the appropriate means of implementing that information in their lives in order to prevent new HIV infections, is a considerable challenge. In general, women are less well informed about HIV than men; the rural population generally knows less than city dwellers.

The effectiveness of prevention programmes is affected by the following factors:

• the general level of education of the population sector and their access to information about HIV/AIDS and psychological counselling.
  
  
• the degree of gender equality and poverty reduction.
  
  
• the protection of human rights in normal life as well as in situations of war and civil war.
  
  
• the elimination of marginalization(*) and stigmatization of certain population groups (prostitutes, drug addicts, homosexuals).
  
  
• For Churches it is of particular importance to consider how the issues connected with HIV/AIDS will be dealt with theologically and can be expressed in sermons and spiritual guidance, pastoral work and community life, as well as in the open attitudes and declarations of the Churches and their officers.

Work to improve these framework conditions must be intensive and ongoing. At the same time, it is critical for further HIV infections to be prevented and for the progression of the disease in people who are HIV positive to be delayed. This requires direct prevention work to be qualified, intensified and expanded in order that clear and sustainable progress can be made with regard to the urgently needed behaviour change.

Many African cultures have a strong community spirit ("I am, because I am a part of the community"). Prevention work must take this into account. This offers certain benefits, in that the community assumes particular responsibility for the people affected by HIV/AIDS. However, there are also specific dangers with regard to particularly vulnerable groups within the community and the possibility of individually responsible attitudes to sex. This makes great demands of prevention work.

General information and awareness-raising campaigns are not enough for prevention. Information alone does not result in behaviour change. For that reason, the Voluntary Counselling and Testing(*) (VCT) prevention approach aims to enable people to arrive at a sustainable change in their behaviour: it provides the knowledge and individual skills that make it possible for people to adopt a responsible approach to their positive or negative HIV status. This means that prevention work is not only focused on the acute stage of AIDS.

AIDS prevention also encompasses the "ABC strategy", which is also known as the "Prevention ABC". Experts(20) distinguish between the following terms:

1. For people who have tested negative for HIV: Abstain - Be faithful - Condomize. This involves either abstaining or remaining faithful to one sexual partner, or if neither is possible, the use of condoms. One must note, however, that women have no means of ensuring the efficacy of these methods if their male partners do not comply with them.
   
   
2. For those who have tested positive for HIV, in addition to abstinence, faithfulness and condom use, one must add: Acknowledge - Belong - Competence. This includes accepting that one has been infected, joining self-help and support groups, and learning about the illness and its course, about necessary testing, and about nutrition and other behaviour.
   
   
3. One further ABC Strategy is crucial to people living with AIDS: ARV (anti-retroviral drugs) - Belief - Care: Taking care to take anti-retroviral drugs properly, coming to terms with one's own faith beliefs (and coming to terms with one's own life and death) and seeking out necessary care.

In the years to come, it will be crucial for preventative efforts to shift from programmes of general preventative information toward programmes that teach and enable each individual to translate the various elements of the ABC prevention principles into a change of behaviour. The underlying procedure, involving voluntary counselling and testing (VCT), has already been introduced in many places, at least to a degree.

The churches bear particular responsibility in this regard and an increasing number of churches have now in fact integrated the internationally recognized and implemented "ABC Strategy" into their HIV prevention programmes. The use of condoms, however, continues to be a matter of controversy in many churches. Certain churches, including some of considerable size, recommend only abstinence and faithfulness to the exclusion of condom use. The regular and correct use of condoms is, however, a major part of the "safer sex"(*) strategy. Comprehensive campaigns to support condom use have been successful in reducing the rate of HIV infection in a large number of countries (particularly in North America and Europe, as well as in Thailand).

However, religious and cultural constraints on campaigning too strongly for condom use prevail in many countries. Churches sometimes argue that supporting condom use is morally unacceptable as it could encourage a general rise in promiscuity, and that condoms prevent conception as well. For most people in developing countries, having children is indeed a matter of existential proportions. In the minds of many, moreover, condoms are tied to prostitution and to extramarital and premarital sex, and are thus additionally objectionable. Many men are also convinced that only unprotected intercourse can be a source of real pleasure. And, furthermore, condoms are neither universally available nor does everyone know how to use them properly.   

Many young women and men are in a phase of their lives in which they are only partially able to make decisions concerning their own sexuality. Campaigns that focus on HIV/AIDS prevention through abstinence - without taking the living conditions of young people into consideration - thus often fail to meet expectations. Education for young people, and sex education for girls in particular, is of particular importance in preventing HIV infections. Sex education kindles an awareness in young people of the dangers of HIV and of unwanted pregnancy. This can promote condom use and a delay to the onset of sexual activity. Sex education also provides girls with a better understanding of their own bodies, greater self-confidence, and consequently a stronger position from which to discuss matters with their partners such as sexuality, contraception and condom use.

In the future, microbicides(*), chemical substances that are applied to the vagina, may prove to be an effective preventative measure for girls and women. A variety of substances are currently in development, although it will take at least five years before they can be introduced to the market. Microbicides and condoms for women(21) are women-controlled options for HIV prevention, requiring less male cooperation than conventional male condoms. The first results of controlled studies among heterosexual men in Africa have shown that circumcision provides a degree of HIV protection. This could add a relatively uncomplicated and inexpensive method of HIV prevention if this result were to be borne out in further studies.

3.3.4 Treatment and prevention in Germany

Antiretroviral drugs now provide HIV patients both with a longer life expectancy and a new outlook on life. One result of this could be a shift in the pastoral care of people with AIDS from a focus on end-of-life hospice care to one on helping them to move ahead with their lives. Treatment is, however, not guaranteed equally to all patients, not even in Germany. Foreigners without residency permits generally do not have the access they need to medical care. People from high-prevalence countries(*) and others who are infected while abroad often first discover their infections during a late phase of the illness, and are thus at risk of having a more limited therapeutic success. As a result of the reorganization of Germany's social security system over the past few years, access to the best life-preserving therapies is no longer guaranteed for many HIV patients. Health insurance companies, for example, no longer always provide coverage for these costs. Related social problems have also worsened, leaving many HIV patients alone with their fears of marginalization and isolation, and of suffering and an early death.

Two German institutions have been working on HIV prevention since the mid-1980s: While the "Gib Aids keine Chance" ("Don't give AIDS a chance") campaign of the Federal Centre for Health Education (Bundeszentrale für gesundheitliche Aufklärung - BZgA)(22) is geared towards the general public, Deutsche Aids-Hilfe e.V. (DAH)(23) is a self-help organization with prevention programmes for particularly vulnerable groups. Another organization, Deutsche Aids-Stiftung ("German AIDS Foundation" - DAS)(24) deals mainly with the social dimensions of HIV/AIDS.

For some time now, concerns have been raised both by a rising rate of sexually transmitted diseases and by a (somewhat less precipitous) rise in the rate of new HIV infections among homosexual men. Possible explanations for this include:

• Prevention campaigns have lost some of the intensity they had during the early years of the epidemic;
  
  
• People are beginning to grow weary of preventative measures;
  
  
• AIDS has been in a process of normalization and banalization;
  
  
• The topic has been receding in public awareness.

A large number of people have developed a false sense of security, imagining that HIV no longer poses a threat and that protective measures are no longer required. We must be decisive in fighting this erroneous notion. The threat of an outbreak of epidemic proportions still looms, even in Germany. HIV prevention measures should therefore be boosted - instead of being curtailed. These measures must especially be extended to people who are more difficult to reach such as immigrants, prostitutes and drug addicts. The particularly rapid rise in the infection rate among people from high-prevalence countries(*) requires particular attention, as they often lack the necessary access to medical and psychosocial care.

3.4  Children with HIV/AIDS, orphans, children and adolescents at risk

Children and adolescents can be affected by HIV/AIDS in various ways. Some are infected themselves, while others live in families affected by HIV/AIDS or even lose their parents to AIDS. HIV/AIDS can also reduce young people to poverty, destroying any future opportunity. As of the end of 2006, 2.3 million children under 15 years of age lived with HIV/AIDS, over 2 million in Sub-Saharan Africa alone(25) In 2006, 380,000 children died of AIDS, while 530,000 children were newly infected with HIV, mostly via mother-to-child transmission. Most of these children die before reaching the age of two, although some survive to the age of 5 or even longer, depending on factors such as nutrition and medical care.(26)

HIV/AIDS impairs and destroys the lives and futures of millions of children whose families are affected. Children who live in poor households that include adults with AIDS are particularly subject to malnutrition and its effects such as stunted growth. Children can also be traumatized by taking care of their parents until their deaths. The loss of their fathers, mothers, or both parents affects the children's well-being in every way, including their emotional and physical health, security, and mental and social development. Their parents' deaths can also often lead to stigmatization, isolation, and curtailments of the children's human rights.

As of the end of 2006, there were an estimated 15.2 million orphans in the world due to AIDS, of whom 12 million were in Sub-Saharan Africa. The number of orphans could rise to some 20 million by 2010 if major measures are not introduced to treat the disease.

Due to their vulnerability, children and adolescents have been one group for whom the churches have always felt a particular responsibility. Many church parishes run programmes for orphans to satisfy their material, social and emotional needs. Orphans are more likely to be the victims of sexual exploitation, child labour, violence and abuse. The churches cannot, however, come close to meeting all of these needs due to the large and growing number of orphans and the impoverishment of the parishes.

Germany's Protestant churches and its Christian aid organizations are increasing their efforts to encourage and enable church parishes to provide for these children. Orphans should be cared for within their own (extended) families or in foster families as much as possible. Orphanages are more expensive by comparison, and often face financial uncertainty, while the children there are removed from their family surroundings. Orphanages should thus be a last resort in helping these children when no other options are available.

3.5  Overcoming taboos and stigmas

HIV/AIDS is often the subject of taboos, denial and prejudice. The close connection between HIV/AIDS and topics that can be sensitive or taboo, such as poverty, sexuality, unequal gender relations, prostitution, homosexuality, and drug addiction, makes fighting the illness particularly difficult. The very long incubation period(*) exacerbates this even further. While the number of those infected rises rapidly during the first phase of the epidemic, only few begin to take ill right away. For many, this creates the illusion that the illness does not pose a real threat, making it easier for people to avoid thinking about the problem. This sort of denial, both at congregational and national levels, leads to neglect in dealing with the illness and, subsequently, to the further spread of the epidemic.

HIV/AIDS is often connected to stigmatization and discrimination. People infected with HIV are disadvantaged and treated unjustly in society, including widows and orphans. It is a common false assumption that HIV infections result only from prostitution and extramarital sex.

Since the risk of infection is high in many prisons, education programmes should be provided to both prisoners and prison personnel alike. Protective measures (especially condoms) should also be made available to prisoners.

Many churches have now recognized that, as the result of taboos, stigma, and denial, they have often exacerbated the HIV/AIDS problem themselves more than they have contributed to solutions. Over the past few years, the churches have begun new efforts with positive new approaches toward undergoing self-critical reflection and overcoming stigma.

In December 2003, for example, the "Strategy Consultation on Churches and HIV/AIDS in Central and Eastern Europe" established that the "political, social and economic changes in Central and Eastern Europe throughout the last two decades have made certain population groups vulnerable to HIV/AIDS." These groups include children and youth, women, prisoners, and drug users. The statement called for care for these groups in particular since as "Christians, we are called to care for and support all those in need regardless of social status, religion, lifestyle or health condition."(27) The founding of the African Network of Religious Leaders Living with or Affected by HIV and AIDS (ANERELA) in 2003 represents another promising step towards the integration of people with HIV into the church.(28) The organization includes pastors and lay church leaders who are either HIV-positive themselves or otherwise affected by HIV. The network has the potential to achieve greater recognition in the churches for people living with HIV/AIDS.

3.6  Global commitment and the mobilization of financial resources

The difficulties that developing countries have in fighting the AIDS epidemic effectively are also a reflection of a lack in available resources. Such countries, for example, often spend more on servicing debt than on health and education. HIV/AIDS can, however, only be contained and defeated if the necessary means are available. This poses a particular challenge during steep rises in financial needs due to the increased spread of HIV/AIDS. Preventative measures then need to be intensified just when an increasing number of people require treatment and care. Treatment must also continue throughout each patient's life, in contrast with other illnesses such as tuberculosis, which, once successfully treated, require no further intake of medicine. This means that, in the case of HIV/AIDS, the number of people in treatment programmes never ceases to rise.

Yet it is not an option to never even start medical treatment, as is still sometimes suggested. We are ethically obliged to save human lives. Mere economic calculation demonstrates that the financial and social costs arising from the death of a young adult far surpass the cost of antiretroviral therapies.

At the United Nations General Assembly Special Session on HIV/AIDS (UNGASS) in 2001, the member states committed themselves to a considerable increase in financial funding for the international campaign to fight HIV/AIDS, and to specific goals in HIV prevention and treatment.(29) The United Nations, with the support of governments and non-government organizations, also decided to establish a Global Fund to Fight AIDS, Tuberculosis and Malaria(*) with the aim of securing the funds needed to fight these three illnesses, which combine to pose the greatest health threat to the world's poorest countries.

Since its establishment in 2002, the Global Fund has authorized 6.8 billion USD in funding for five-year HIV/AIDS programmes in 136 countries. The programme has afforded antiretroviral treatment to some 770,000 patients to date, and has paid for over 1 million HIV tests with counselling services. In total, over 1.6 million people will receive antiretroviral treatment in the course of the five-year projects that have been authorized thus far. The Global Fund's long-term financial needs have not, however, been adequately met over the past few years, with financial commitments falling far short of the amounts required to meet the goals set by the United Nations. A "replenishment process" was therefore set into motion in 2005 in order to provide reliable and sustainable financial support for the Global Fund that can be planned long in advance, as is usual for other international financial institutions.

In addition to the Global Fund, other major international financial instruments and programmes have emerged in the struggle against HIV/AIDS: The World Bank's Multi-Country HIV/AIDS Program for Africa has provided over 1 billion USD, while the American President's Emergency Program for AIDS Relief has made 15 billion USD available to 15 countries over a period of five years. This has all contributed toward a strong increase in funds available in the fight against AIDS.

Such funds are also available to churches for use in the expansion of their commitment to combating HIV/AIDS. This requires that the churches comply with international standards in the execution and evaluation of their programmes. Many governments of developed countries, including Germany, have also made fighting AIDS into a focus of their bilateral developmental efforts.

Using state and multilateral funding to finance church HIV/AIDS programmes can, however, also lead to difficulties. A 2005 consultation in Bossey, Switzerland(30) held by organizations including the World Council of Churches, Caritas Internationalis and the Deutsches Institut für Ärztliche Mission e.V. ("German Institute for Medical Mission" - Difäm)(31) pinpointed major difficulties in the financing and administration of HIV/AIDS programmes. These included deficiencies in educational, technical and other capacities, a lack of network resources, and donor requirements perceived to be overreaching and overly restrictive in the work of the churches.

In addition to their own financial support of HIV/AIDS programmes, church development agencies should also assist their partners in applying for other governmental and multilateral resources. It is also important that information be exchanged on rapidly changing conditions and guidelines in areas such as diagnosis and treatment; that enough people are employed to meet expanding needs, especially when it comes to the management of additional funding; and that networks are financed through church funding if they are not funded otherwise.

Financing for the fight against AIDS must be secured with long-term stability. In addition to the financial instruments used so far, new recommendations for priorities in developmental cooperation are now under discussion. These ideas include an International Finance Facility, which would increase short-term developmental aid by issuing capital market bonds, the introduction of a tax on international currency transactions, and taxes on air travel such as the one already introduced in France. Poor countries can be afforded greater long-term financial support in their fight against AIDS in ways such as: the May 2005 decision of the EU to gradually approach its goal of spending 0.7% of its gross national income on aid by 2015; the debt cancellation scheme that was decided at the July 2005 G-8 summit in Gleneagles; and the decision to spend 44 billion euros on the fight against infectious diseases at the June 2007 G-8 summit in Heiligendamm.

 

Footnotes:

10 See Weinreich, S., Benn, Ch.: Aids - Eine Krankheit verändert die Welt. Daten - Fakten - Hintergründe [AIDS - A Disease that is Changing the World. Data - Facts - Contexts]; Frankfurt 2005.

11 See "Schritte zu einer nachhaltigen Entwicklung. Die Millenniumsentwicklungsziele der Vereinten Nationen. Eine Stellungnahme der Kammer für nachhaltige Entwicklung der EKD zur Sondervollversammlung der Vereinten Nationen im September 2005" [Steps to Sustainable Development.The United Nations Millennium Development Goals, A Statement by the Advisory Commission for Sustainable Development of the Evangelical Church in Germany] EKD-Texts 81, Hannover 2005.

12  See Sachs, J. et al.: Investing in development: a practical plan to achieve the Millennium Development Goals, 2005 (www.unmillenniumproject.org/reports/index.htm).

13  See Ruxin, J.: Emerging consensus in HIV/Aids, tuberculosis, malaria, and access to essential medicines, Lancet, Vol 365, Feb 12, 2005.


14  See the outcome document of the World Summit 2005, paragraph 57.
 (http://daccessdds.un.org/doc/UNDOC/GEN/N05/487/60/PDF/N0548760.pdf?OpenElement).

15  All Africa Conference of Churches: The Covenant Document on HIV/Aids,
 www.wcc-coe.org/wcc/what/mission/ehaia-html/cameroon-covenant-e.html)

16  See the outcome document of the 2005 World Summit, paragraphs 58 und 59
(http://daccessdds.un.org/doc/UNDOC/GEN/N05/487/60/PDF/N0548760.pdf?OpenElement).

17  The 3 by 5 Initiative was launched on World AIDS day 2003 by WHO and UNAIDS with the aim of making it possible for three million people (3) in developing countries to have access to antiretroviral therapy by the end of 2005 (5). The aim was to reach at least half of the six million people estimated to be in need of therapy worldwide. At the end of 2005 however only about 1.3 million people were provided for. Nonetheless WHO considers the Initiative to have been a positive catalyst and trail-blazer for the new initative "Access for All", which will achieve its goal in 2010.

18  See UNICEF: Children and Aids. A stocktaking report. Actions and progress during the first year of Unite for Children, Unite against Aids, 2007;
(http://www.who.int/hiv/paediatric/stocktakingreport.pdf).

19  www.ems-online.org/77.html

20 In a working-paper of the World Council of Churches it is critical remarked that this prevention-abc without any differential reflexion could effect to stigmatise people and to detain them from secure sexual practises . To avoid this an alternative model of prevention under the acronym "SAVE" is propagated. SAVE means Safer practise, Available medications, Voluntary counselling and testing and empowerment through education. The aim is to combine components of prevention and treatment and to face the stigmatisation. (World Council of Churches, Towards a Policy on HIV/Aids in the Workplace - Working Document, 2006, S. 3f; www.wcc-coe.org/wcc/what/mission/workplace-policy-e.pdf).

21 Female condoms have been available for women since the 1990s. These condoms are some 18 cms long and feature two rings. The outer ring is placed outside the vagina in front of the labia majora and the inner ring is inserted into the vagina like a diaphragm. Sales in female condoms did not meet expectations due to the complicated nature of their use, leading to a significant reduction in their availability.

22 www.bzga.de

23 www.aidshilfe.de

24 www.aids-stiftung.de

25 Cf. UNAIDS / WHO: AIDS Epidemic Update, December 2006,
(http://data.unaids.org/pub/EpiReport/2006/2006_epiupdate_en.pdf) and UNICEF: The State of the World's Children 2006: Excluded and Invisible
(www.unicef.org/sowc06/pdfs/sowc06_fullreport.pdf).

26 Cf. UNICEF: Children and AIDS. A stocktaking report. Actions and progress during the first year of Unite for Children, Unite against AIDS, 2007
(http://data.unaids.org/pub/Report/2007/20060116_stocktaking_report.pdf).

27 www.wcc-coe.org/wcc/what/mission/petersburg.html

28 www.cpsajoburg.org.za/hivaids/anerela1.html

29 United Nations (2001). General Assembly Special Session on HIV/Aids Declaration of Commitment (www.unaids.org/UNGASS/index.html).

30 www.e-alliance.ch/hiv_accessingresources.jsp

31 www.difaem.de