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"The objective of this article is to introduce an HIV prevention strategy that may actually work in married and other committed relationships: Teaching committed couples how to have better sex, this reducing the need and incidence of infidelity. And yes, this implies the absence of condoms. Why?

We need to distinguish between relationships with procreational versus recreational sexual objectives in HIV education and prevention strategies. The reason is simple: Couples want babies, which means condoms are simply not used. The statistics regarding condom use in this category of at-risk population speak for themselves: Condom use is high - and effective - in youth and sex worker sectors, but not elsewhere, at least in the developing world. As stated, the reason is simple: People want children when they get married or commit to each other in the long term. This aspect of committed relationship is deeply entrenched, and reinforced culturally and via religious institutions.

At the same time, the statistics show that a woman who gets married doubles her risk of infection the day she gets married, because she loses the cultural and religious right to protection (i.e., condoms) when she gets married: She now needs to conceive. The question is: How do we protect her, her husband, and her children?

Here are the realities we have encountered: (a) Often, it is considered acceptable for the husband to have extramarital sex, as long as he provides for his family. We do not agree that this is an intrinsically traditional cultural norm: Our experience is that this norm is relatively new, but present nevertheless; (b) The wife may not actively prevent conception through condom use, even if she knows her husband is being unfaithful. The situation is not the same as contraception through other means, which are largely invisible to the husband. A condom requires his full attention and participation, which rarely occurs; (c) The consent of the husband is the key to condom use. This can be circumvented through the use of femidoms, but they are difficult to obtain, relatively expensive, and conspicuous unless carefully used. The husband's consent is only obtained - sometimes - after several children have been born, and the couple assured that the procreational aspect of their relationships is fulfilled. What do we do till then?

When a man asks his wife to have sex other than in the standard missionary position, she accuses him of treating her like a sex worker and is offended. Often she will go to her mother to complain who in turn will go to the husband's father and he then questions his son as to why he is treating his wife with such disrespect. So this is the man's justification for having sex outside the marriage: 'I want better sex with my wife, but she won't let me have it.'

The next logic step was for us to speak to the wives. So we did, and asked why they refuse to have sex other than in the standard position, the response was that 'I am never asked what I like in sex, if I like
sex and if I even want sex so why should I do anything that gives him pleasure. He doesn't care about me and my sexual needs so I will simply lie there, let him do his business..why should I give him pleasure? If he wants that then he must use a working girl.' So it's a case of two wrongs and neither making a right.

We are aware that these reasons are the surface rationales that disguise a range of dysfunctional communications and role definitions for men and women in sexual relations. For example, it is common practice to suppress sexual pleasure in women, whether through the practices of 'dry sex' (i.e., removal of vaginal fluids before sex, to maximise friction -thus pleasure - for the man); clitoral circumcision, and so forth. For women, sex is often painful, and few connect it with pleasure.

The only conclusion we can arrive at is the following: Neither husbands nor wives particularly enjoy sex with each other. Furthermore, there is anger and resentment from both sides regarding this situation, which leads to high-risk sexual activities outside of the marriage. Is it much wonder that there is such resistance to sex education, if it is a source of frustration and often - for women particularly - pain?

Furthermore, if a wife does not conceive and bear children, she if often rejected by not only the husband, but by the community too. When this situation is placed within a context of gender inequity and often strong cultural and religious role definitions regarding sex, it appears that the situation is extremely difficult to change, at least from a HIV prevention perspective.

Here is what we propose as a solution:

What if we used the structure of religion, to teach people in committed relationships how to have better sex? What if religion started taking an active role in human sexuality and relationship-building through educated intimacy? Sounds simple, but when you think through the methodology, it will become abundantly clear that this approach will also have a radical impact upon gender inequity, for the simple reason
that the best sex is dependent upon a disciplined effort to communicate and learn about your sexual partner.

Why religious structures, such as ministers and priest? The reasons are more practical than anything else: Religion as an institution is the most vulnerable to the impact of HIV/AIDS in their married congregation.

Quite simply put, the very institution of marriage is under threat. By endorsing and facilitating marriage, churches are facilitating women -in particular - in shifting to a higher HIV infection risk category. Under the banner or morality (e.g., no sex before marriage; go forth and multiply, etc), religion is putting women at risk, unless they simultaneously provide the practical methods for avoiding such risks.

Protestant morality permits condom use within marriage, but still supports marriage as the appropriate place for procreation; Catholics do not permit condoms within marriage, and the same can be said for other
non-Christian religions.

It is true that all main-stream religions strongly discourage infidelity. So they think they are off the hook on the morality aspect.

Not quite: it is an illusion - and currently, a life-threatening one - to pretend that committed relationships will endure through simple 'thou shalt not' proscriptions. It is time that the religious institutions started figuring out what 'thou shall do', to prevent the disintegration of the sacred nature of marriage. The time for shouting the moral odds from the side-lines of sexual activity is over, unless you are content to see the game end, permanently. It's time for religion to update it's commitment to protecting the sanctity of marriage, and getting a little more involved in the mechanics of the process. People - married people - need help, and they need it from people they trust. It is not acceptable that people are told where (married, not married) they can have sex, without any instruction on how sex can be experienced as sacred.

This is where religion can play a huge corrective role in this pandemic: Imagine the following: A young couple approach their families to inform them that they are in love, and intend to get married. The families are delighted, and make an appointment with the minister/priest of their religion. Over the next six months - individually at first, and then later as a couple - the couple are given instructions in the art of relationships, trust, communication, and sex. No, they do not have sex until they get married. The couple discuss love, love-making, fears, pleasures, children, their future, and a range of issues which create an intimate bond of understanding and trust. During the first few months of marriage, the instruction continues, with exercises to enhance sexual experiences, and to consolidate trust and communications. Breathing and muscle control exercises are included, to prolong orgasm, the difference between orgasm and ejaculation, and a range of information that ensures that the sexual experience between the husband and wife is of such a nature that sex outside of marriage becomes unthinkable, and certainly not appealing.

Impossible? Not at all! These skills exist, and those that practice them are very adamant that the best sex possible can only be achieved within a relationship of love and trust. Extramarital sex is simply not as good.

Many religions have made sex a taboo subject, blamed it for AIDS, and have used the pandemic to further instil/impose their values without even trying to meet people where they are and not where they feel they should be. In a nut shell, religion, by and large, has made sex the problem and what we are suggesting is that they can use sex as the possible solution. Sex, from my understanding and experience can be an incredibly spiritual revitalization.

We would also like to highlight one additional benefit to this notion: Great sex can only be achieved with disciplined communication. That means both ways. I.e., husbands - in order to have the best orgasm of
their life - will need to communicate with their wives about sex, built trust, and essentially treat them with tenderness and respect. Apparently, this is called love.

We can also imagine that young (unmarried) men will be pitied by married men, for not having access to great sex, instead of the reverse!"

Reprinted in its entirety with permission from the author, David Patient.