13 HIV Transmission and Prevention: Needle Exchange and Condom Distribution?

Walking the streets Giving out clean needles?  Encouraging a drug habit or saving lives?  Contraceptives for unmarried people?  We are all involved in `grey' areas  All the prevntion options may feel wrong  Prostitution makes us think  Missionaries make difficult choices  Life-and-death choices  Befriending or confronting?  Drug rehabilitation goals changed by AIDS


CHAPTERS: Introduction  1 The Extent of the Nightmare  2 What's so Special about a Virus?  3 When Cells Start to Die  4 How People Become Infected  5 Questions People Ask  6 Condoms Are Unsafe  7 Moral Dilemas 8 Wrath or Reaping?  9 Some Life and Death Issues  10 When Church Members Need Help  11 Others Need Help Too  12 Saving Lives  13 Needle and Condom Distribution?  14 Special Issues in Poorer Nations  15 A Ten Point Plan for the Government  16 A Global Christian Challenge  Appendix B  Appendix C  Appendix D 

Note:  This chapter of The Truth about AIDS by Dr Patrick Dixon is the original text as published by Kingsway in 1994 updated in 2002 and may be reproduced with acknowledgment.  Search this book.

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• Moral dilemmas - euthanasia and AIDS treatments
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• HIV Prevention - needle exchange program and condom distribution
• AIDS in Africa and HIV in Africa, HIV infected surgeons
• Ten point AIDS management plan for governments
• A global Christian challenge - church response to AIDS
• Guidelines for best practice in running HIV / AIDS programmes in developing countries, plus many helpful case studies and stories (Africa / India / Asia)
• A Christian response to AIDS - global AIDS challenge to the church (article for Tear Fund)

While a church organisation can find doors open easily into schools, and the general approach required fits well with Christian values, when we look at other areas of community prevention things can become much more difficult.

It is far easier to bring HIV or AIDS into other aspects of existing work than to set up new programmes. Examples of this might be detached youth work, work in pubs and clubs, among the homeless or among commercial sex workers.

Walking the streets            (return to index)

Detached work can be very successful in reaching all kinds of marginalised groups. Two or more people go out onto the streets, heading for areas where people are known to hang out, especially in the evenings. It might be outside a takeaway food shop on a big estate, or at the bottom of a particular tower block.

Friendships are formed and in that context other things can happen. For example, people can be invited back to someone's house, or literature given out about HIV on the streets. The aim is to create a situation where individuals or groups become interested, and ask questions about how they can protect their own health.

In Dublin, detached workers from ACET Ireland have made contact with a drug-using community who are, to a large extent, outside contact with health services. A number are ill or dying, and many are infected with HIV. Others have become friends. While other agencies or care workers are sometimes unwilling to go into certain areas, with great fears for personal safety, we have found this community accepting and protective in attitude.

Giving out clean needles?            (return to index)

In Dundee, Scotland, drug users gather round as soon as you drive onto various estates with an(unmarked) van. Often they talk about friends who are unwell and need help. When in their homes, there is also a chance to talk to others about safe injecting and how to save their own lives or the lives of their partners and friends.

This brings us straight into another area of difficulty. Some are injecting with shared equipment because they have no needles of their own. They do not want to give up. Should we issue them with clean needles on an exchange basis---in other words, take a blunt one and give them a fresh one? Are we back onto the argument of just teaching people to `sin safely'?

Needle exchange programmes have been very successful, dramatically lowering the incidence of needle sharing. However, one problem is that needles do not always come back---sometimes only half do---raising fears that while HIV infection rates may fall, the numbers injecting may rise. The whole issue is very controversial in many countries.

Encouraging a habit or saving lives?            (return to index)

Christians find it is easy perhaps to decide what is right or wrong behaviour, but when confronted by different situations, it can be less easy to know what to do. Let us imagine that you are a worker visiting people ill and dying with AIDS on a big housing estate in Scotland.

Over a period of months, you gradually get to know a group of drug injectors who have no contact with any other source of help. Several need care, and several want to break the habit. You organise help for these people. However, despite your conversations about the dangers of injecting with shared equipment, three of them tell you they will do so again tonight because they only have one needle and syringe between them.

There are several options open to you. You could inform the police and get them all arrested following a raid on the flat. If you do that, you will violate the trust of the group, you and your organisation will never be asked to help again, and those dying on the estate will die without any help at all. Drugs are also freely available in most prisons, so you will have done nothing to solve the basic problem.

You could just turn your back on the situation and walk out, leaving them to infect each other with a warning about the danger, knowing that one or two of them may receive a death sentence that very night from HIV infection.

There is another option: you could decide to help them on their own terms. Despite all your efforts, they are going to continue to take big risks. They are addicted to the habit and are happy to remain so. You could explain that rinsing the needle and syringe with a freshly-made solution of bleach in water (one part in ten) before passing the equipment on will reduce the risk of death from AIDS enormously. This is not just a matter of morals; this is quite literally a matter of life and death.

If you decide not to tell them this and walk away, and a few years later you are cradling one of them in your arms as he dies, because he became infected that night you walked away, will you not feel an element of responsibility for his death? Perhaps you can distance yourself from this situation, but what if it was all much closer to home?

What if the drug user was your own teenage son or daughter? Would you not do all you could to encourage your own child to use bleach if he or she was determined to continue injecting with shared needles or syringes? If your own child was about to go to the house next door to borrow a bloody needle from someone you knew had AIDS and you happened to have a clean needle in the house, would you not feel perhaps a need to offer a clean needle? If your son is infected that night, will you not feel you could or should have prevented the tragedy? These are not hypothetical situations. Similar agony or conflict is an ever-present reality for many Christians caring in the community, and unfortunately for some Christian parents.

We need to find the way of Jesus. What would he do? Jesus was always honest, open and hard hitting in what he said, yet compassionate and loving in what he did. I cannot believe that Jesus would sit watching the person injecting death without a warning to stop, and, if disregarded, then giving advice on at least how to clean the needle properly, taking care of hygiene. If he knew there was a box of new needles in the corner, I can imagine him mentioning it. Not to promote the practice, but to save life until a time when the person may be looking for help out of addiction, and for reconciliation with God.

I have met a Christian who told me that he would rather sit and watch his son die than tell him how to inject safely. What kind of a dad is that? Some parents are so severe with their children---no wonder so many teenagers of Christian families reject their parents' faith. Often teenagers are saying: `If this is Christianity, then you can keep it. It's horrible.' Life in the home is vitally important, because it is there that people see the reality of how we are. What kind of gospel are we living? We need to recognise that even where parents have been wonderful examples, children can rebel, rejecting not only parental authority, but also parental values and faith. We also need to see that doubt is a big issue for many people.

Another churchgoer told me that if her son ever showed any signs of growing up with a same-sex orientation she would throw him out of the home, disinherit him and never see him again---even if he was celibate. What has such harshness got to do with a loving heavenly Father? I shudder to think what would happen if God judged these parents with the ferocity with which they are judging their children.

Jesus said: `Do not judge, or you too will be judged. For in the same way as you judge others, you will be judged, and with the measure you use, it will be measured to you.' So take care. You had better be near perfect or you may be rightly accused of hypocrisy. Of course, as we have seen in Chapter 8, there are clear standards and we are called to challenge, rebuke and confront where necessary.

We need to understand that Jesus often behaved in a way that people thought might appear to be encouraging others to do wrong. As far as the spiritual leaders of the day were concerned, he showed a profound lack of judgement and gross indiscretion in the relationships he formed. Jesus was heavily criticised for encouraging either financial corruption or sexual immorality by publicly associating, eating, drinking and making friends with `tax collectors and sinners'.

They felt Jesus was giving out a very dangerous signal that wrong behaviour was acceptable, and that despite what he said about God's standards, he was actually encouraging these lifestyles. It is the same today. There are some in the church with rigid black-and-white views on what is absolutely wrong and what is absolutely right in absolutely every situation. They would have had exactly the same problems accepting Jesus as the Son of God as the passionately committed Pharisees did 2,000 years ago.

After much careful consideration and prayer among the team, we felt that we should issue a limited number of replacement needles on an individual basis to some we knew who were injecting, whose needles were blunt, who were unwilling to stop and who would be using other people's needles unless replacements were found. This was not an easy decision and some will criticise us for it. Perhaps the reasons will become clearer as you read on.

It is interesting that Christian doctors, nurses, social workers and missionaries living in the real world usually understand, with many coming to the same conclusions. It is usually those whose lives are most sheltered from the daily lives of those at the margins of society who have the greatest difficulty. Yet that was exactly where Jesus was always found: with the marginalised, the poor, the outcasts, the oppressed, those who had dropped out or rejected the common view of what was right or wrong.

The issue of needle exchange is an entirely different issue to giving out condoms to children in schools. We would not give out needles in school corridors either. The equivalent of needle exchange regarding condom distribution might be a church running a Christian pregnancy advisory service.

We do need to help people find ways to say no if they are feeling under pressure to have sex, and to help them understand the risks they may be taking. However, most Christian doctors I have spoken to in General Practice do recognise that there can be circumstances under which they feel it might be appropriate to provide people with condoms. The issue of contraceptives for under-sixteen-year-olds is far more controversial, especially if this is done without parental involvement. If refused, the next request could be for abortion.

Incidentally, I would always prefer advice to be given, if possible, in the context of the family doctor's surgery, but young people are not always willing to go there because they are afraid that Mum or Dad will find out.

Contraceptives for unmarried people?            (return to index)

Ethical dilemmas are faced by Christian doctors and nurses every day. I am not saying it is possible to be certain about all the answers, but it is important that we face the questions. It is too easy to hide behind a sermon or to withdraw into the Christian ghetto of church social life and hope these things will go away. We need to preach practical faith that helps people to live in the real world; not platitudes that just comfort us when we return to our homes at night.

We face conflicting ethical issues when someone who is unmarried asks for contraceptives. In the past, family planning clinics in the UK would only help married women. I am not sure many Christians would want to insist on such a rigid approach today, any more than they would want a law passed making sex outside of marriage illegal, as is the case in some Islamic states. However, it could be argued that giving free contraceptives to people who are living together is directly encouraging immorality.

Exactly the same thoughts can apply to helping those with a drug habit. We need to be consistent. What is the answer? It seems to me that first we need to provide the best possible rehabilitation facilities for any who would like to come off drugs. Secondly, we also need to offer the best health advice for those who want to continue injecting.

If we follow the same line as with unmarried men and women who want protection against pregnancy, then we will be willing to supply not only clean needles, but also bleach for sterilising.

Some say that we are then being inconsistent about condoms in schools. I think there is a huge difference between agreeing to make condoms available to adults wishing to reduce the risk of pregnancy or HIV, and promoting such methods to children or young teenagers.

We agree that adults, by definition, are of an age and maturity to form their own judgements and to make their own choices. In contrast, we accept that young teenagers have a developing maturity which is particularly susceptible to influence and pressure. For good reason, there is widespread concern that giving out free condoms in schools will send a powerful message that pupils are expected to have sex at a young age. There are enough pressures on young people to say yes to sex. Why add to them?

We are all involved in `grey' areas            (return to index)

Christians are divided on these issues. All I am saying is that we need to be consistent and compassionate. All would agree that needle exchange is not ideal.

The fact is that in many situations, we are faced with limited choices, each one of which will mean thinking through some important principle. The choice to do nothing is no way out because it breaks another principle, which is our duty to respond to human need.

We are being dishonest with ourselves if we think we can avoid these dilemmas, these shades of grey, and live in a world of black and white decisions. Jesus faced dilemmas in his own day---for example, over the issue of whether it was right to heal people on the Sabbath, or whether it was right to condemn a woman who had committed adultery.

All the options may feel wrong            (return to index)

In reality, from time to time we all have to choose options we do not like very much, when something is disturbingly wrong with every option. The reason for this is that we live in a fallen world. Take the example of a child we think may be at slight risk of sexual abuse. We are caught between the desire to protect children and the need of children for parents, knowing how difficult short-term fostering can be and the dangers present in many children's homes.

Another example is the response of the United Nations in the past to Bosnia and Iraq or more recently in the War Against Terror. In each case the autonomy of the sovereign state, and the call to live at peace with each other, is balanced against the need to protect lives, to fight aggression, or to prevent mass genocide. In every situation we need to pray for wisdom and humility, recognising that whatever we decide is the best, there will be others who might take a different line.

Prostitution makes us think            (return to index)

We face the same complex issues when talking with commercial sex workers. As we have seen, there is a strong link between commercial sex and drug abuse. In some cities over half of all sex workers are injecting drugs. Many sell their bodies for sex because it is the only way they can generate enough money to feed a drug habit. Their pimps may be paying them in kind with drugs, food and accommodation.

We can offer those on the street a way out through drug rehabilitation programmes and helping them find new housing and jobs, but many will choose to remain. If they do, then I believe we have the same obligations to teach them to protect their own health and the health of others as we have to educate any other members of our community.

Missionaries make difficult choices            (return to index)

Once we become deeply involved in the community we find very difficult situations to which there are no right answers: every choice open to us presents further difficulties. Missionaries overseas have always encountered these situations and still do so today.

For example, I was talking to someone recently who had been working as a missionary in Thailand. Young girls cross the border from neighbouring countries to work in the cities as prostitutes. Sending a daughter to the big city to work in the bars and sell her body can be as much a natural way of life in some countries as sending children to university is in the UK. Many young girls are expected to work this way and to support their families back home, returning after a few years to settle down and marry. In addition, in some places large numbers of children as young as eight are being sold as sex slaves to brothel owners in neighbouring countries.

The problem now is that many of these sex workers have become infected with HIV. Those from neighbouring countries cannot return home because they have heard reports that those returning are tested for HIV at the border and those found to be infected are led away to be shot or injected with cyanide. The girls are effectively owned by brothel keepers in the city and cannot run away. If picked up they would be deported anyway, as they are often there illegally.

Life-and-death choices            (return to index)

A number of churches have programmes reaching out to such girls, many of whom are becoming ill. Some of the girls have formed close friendships with people in the church---the only friends they have---and have become believers. However, it is hard for them to stop being prostitutes for fear of violence or death at the hands of their masters.

The church is faced with a choice: do we encourage them to stop because their work is against God's law? If so, the church cannot risk sending them back across the border. Does it then hide a growing number of illegal immigrants? Where do you hide them anyway as they are bound to be discovered by the intricate communication network between brothel dealers in the city? If they are taken deep into the country, it is still likely that they will be found eventually. The church will have broken the law and will be in big trouble.

I have been told that at least one church has come to the conclusion that the girls will have to stay where they are for their own safety. They are effectively slaves owned by the brothels since they cannot escape. Therefore, most if not all of the moral responsibility for what they are doing lies with those who are threatening to kill them or to beat them if they do not obey. These are very difficult areas, but just the sorts of things that face us once we move out of our comfortable Christian ghettoes and get involved in what life is like for the rest of the world.

Befriending or confronting?            (return to index)

So then in summary we need to define goals: are we wanting to befriend and help people to continue more safely or do we want to confront and offer a way out? There can be a middle way, which is to provide both approaches in the same team or person, but the exact way you go about it is critically important. You cannot expect to drive into a residential area week after week to meet drug users with disapproving comments, and expect to build friendships and become a source of advice.

In any case, HIV spread among drug users means we need to have a big rethink about drug rehabilitation. People like Jackie Pullinger in Hong Kong have caught the imagination of millions of Christians with wonderful accounts of how God has delivered drug users from addiction---usually from heroin use. The only treatment used is prayer and friendship. They have found no need for medically-supervised withdrawal and they see a very high success rate.

Similar programmes have grown rapidly all over the world. They all work in part by using those who have been through the programme to reach, help and support others.

Unfortunately, while in the past such miracles of new life could sustain a growing work, now many of those who have been through such programmes are found to be HIV-infected. Indeed, many may be ill or dying before their first contact with members of the church.

Drug rehabilitation goals changed by AIDS            (return to index)

We need to redefine our aims. If a drug user is going to die in the next six months with AIDS, is there the same point in weaning the person off? It is true, however, that if a person continues injecting with shared equipment, then he may be adding further damage to the immune system, and may die more quickly.

Is the aim to enable the person to have a good quality of life and to die well, or is the aim to provide a long-term stable and secure future?

In summary, then, community prevention is a vitally important area for the church to be involved in, but it often raises far greater ethical questions than AIDS education in the classroom does. The basic principle of unconditional love leads us to offer help in a broader way than we might initially feel comfortable with. We need to have a clear moral framework ourselves for our own lives, understanding God's standards and his design for living, but we may need to be prepared to offer a modified approach to prevention when helping those who do not share our values.

We want people to be fully aware of health risks so they can make their own choices. We want to encourage people to avoid HIV risks completely as far as possible, rather than just carry on as before with latex rubber, clean needles or bleach as partial protection. Part of teaching people the truth about AIDS is teaching them how to reduce risks. While Christians can then be accused of simply teaching people to `sin safely', we also have to recognise the need to save lives. The key is how advice is given, placing risk reduction in the context of relationships, commitment and empowering people to make their own choices about saying no, taking a long-term view and thinking through what is important to them.

Walking On the streets  Giving out clean needles?  Encouraging a habit or saving lives?  Contraceptives for unmarried people?  We are all involved in `grey' areas  All the options may feel wrong  Prostitution makes us think  Missionaries make difficult choices  Life-and-death choices  Befriending or confronting?  Drug rehabilitation goals changed by AIDS

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