The Impact Of Religious Organizations In HIV/AIDS Prevention In Developing Countries

The Impact of Religious Organizations

in Promoting HIV/AIDS prevention

Revised version of paper presented at “Challenges for the Church: AIDS, Malaria & TB” (Conference Title), Christian Connections for International Health, Arlington, Va., May 25-26 2001. (Available in French)

Edward C. Green, Ph.D.

Consultant, Synergy Project

and Harvard School of Public Health

e-mail: ;

During the early years of the HIV/AIDS pandemic, many people who worked in HIV/AIDS prevention thought of religious leaders and organizations as naturally antagonistic to what they were trying to accomplish. In many minds, the stereotype of a religious leader was that of a conservative moralist who disapproved of any form of sexual behavior outside of marriage (especially male-male sex), as well as what was seen as the "only solution" to HIV infection, i.e., condoms.

Today we have convincing examples of so-called faith-based initiatives in which involvement of religious leaders and organizations in HIV/AIDS prevention has had major impact. (The role of religious organizations in care and support of those with HIV is well-recognized and not the issue here). This paper focuses on developing countries.

“Behavior Change”

“Behavior change” is a term much-used in AIDS prevention circles. It is often used narrowly to mean adopting condoms. But one could argue that the condom option is really a “harm reduction” solution for people who don’t change their risky behavior.

This paper is concerned with what might be called primary behavior change. Examples of this are fidelity to a single partner, sexual abstinence, or young people “delaying” the age at which they begin to have sexual intercourse. It is useful to distinguish these behavioral changes from condom use or treatment of sexually transmitted diseases (STDs), both of which are “harm reduction” approaches. The latter are more passive than the former, and arguably involve less of a personal commitment to fundamental change of behaviors.

If we consider the simple ABC approach to AIDS prevention to which lip service has long paid (Abstain, Be faithful, use Condoms if A&B fail), it is clear that the vast majority of prevention resources have gone to condom promotion, and more recently, to the treatment of the treatable STDs. Few in public health circles really believed—or even believe nowadays--that programs promoting abstinence, fidelity or monogamy, or even reduction in number of sexual partners, pay off in significant behavioral change. My own view on this changed when I evaluated HIV prevention programs in Uganda and Jamaica, and conduced a national survey of behavioral change in the Dominican Republic.

Findings are now presented from three countries that seem to best illustrate the positive impact of faith-based organizations (FBOs), Uganda, Senegal and Jamaica. We will see a pattern of behavioral changes compatible with the prevention strategies favored by FBOs, as well as data showing stabilization and reduction in national HIV infection rates.

Uganda

Uganda is the country that has had the most dramatic decline in HIV infection rates. HIV prevalence declined from 21.1% to 6.1% among pregnant women between 1991 and 2000. In 1987, the major religious organizations in Uganda (Catholic, Anglican, Muslim) became significantly involved in AIDS prevention, with WHO/GPA funding, through the Ministry of Health. By 1992, HIV infections rates were still so high that USAID also decided to allocate some of its funds for FBOs to work in prevention, but on the FBO’s own terms. The FBOs said that they wished to promote "fidelity" and "abstinence" rather than condoms. At the time, many working in HIV/AIDS prevention thought that fidelity and abstinence promotion would have few if any measurable results. However, this approach was and is strongly favored by President Museveni, who is credited with being the most activist African head of state in addressing the AIDS crisis. Museveni stated his views in a speech to the First AIDS Congress in East and Central Africa (Kampala, 11/20/91):

Sex is not a manifestation of a biological drive; it is socially directed…I have been emphasizing a return to our time-tested cultural practices that emphasized fidelity and condemned premarital and extramarital sex. I believe that the best response to the threat of AIDS and other STDs is to reaffirm publicly and forthrightly the respect and responsibility every person owes to his or her neighbor.

As for condoms, Museveni said in the same speech:

Just as we were offered the “magic bullet” in the early 1940s, we are now being offered the condom for “safe sex.”... I feel that condoms have a role to play as a means of protection, especially in couples who are HIV-positive, but they cannot become the main means of stemming the tide of AIDS.

Beginning in 1991, we see a downward trend in both STI and HIV infection rates in Uganda. We also have numerous studies after 1993 documenting behavioral change. Most studies show that reduction in the number of sexual partners (which may be causally related to the "fidelity" message), and delay of sexual debut among youth (which seems to be related to the abstinence message), are the major forms of behavioral change that have occurred in Uganda, more than increased condom use. Condom ever-use is at about 20% nationally. The proportion of Ugandans who report one or more non-regular sexual partners is between 6-8.7%. And about 20-25% of those surveyed age 15-49 report complete abstinence in the past year, most of this attributed to youth delaying first sexual experience (Uganda MoH 2000, 2001 in preparation).

If sizable numbers of men and women reduce their number of sexual partners, can this have significant impact on HIV infection rates? Recent studies by N.J. Robinson and others that have modeled the impact of different interventions on HIV infection rates in east Africa suggest that reduction in number of partners can have great impact on averting HIV infections, in fact greater than either condom use or treatment of STDs.

Decline in infection rates is greatest among the 15-19 age group, and a UNAIDS analysis shows that this was mostly due to the rise in the median age of first intercourse by 2 years, increasing from age 15 to 17. Rise in age of sexual debut among females is particularly important because of the increased biological vulnerability of young females to HIV infection.

It is noteworthy that male condom user levels were only 3-5% in Uganda before 1992. And this refers to the proportion of men who reported “ever” using a condom, not those who claimed regular use. It therefore seems unlikely that condom use contributed to the onset of decline in STI and HIV infection rates, even if increased condom use in subsequent years helped this process. Condoms were not widely available in Uganda until after 1993, and then mostly in urban areas. By 1998, 20% of Ugandans reported ever having used a condom (average national male rate, rural and urban). Some reports continue to claim that the world’s great success story in AIDS prevention, Uganda, owes its achievement to condoms, but this is not true.

It is also worth noting that apart from delay of sexual debut, about 7% of women and 10% of men aged 15-50 reported that they have adopted complete and sustained abstinence for HIV protection in the previous year by the mid-1990s. This rose to over 20% in 2000.

Has involvement of faith-based organizations impacted behavior in Uganda? There is some evidence from impact studies, such as a UNAIDS “Best Practices” study of the Islamic Medical Association of Uganda (IMAU) which shows that AIDS prevention activities carried out through religious leaders has had significant direct impact on particular populations targeted. The Anglican Church of Uganda has also implemented special prevention programs aimed at youth, carried out in Sunday schools and primary schools. Moreover, religious organizations put emphasis (sometimes sole emphasis) on primary behavioral change, on what they called abstinence (or “delay”) and fidelity, and these are the very changes that resulted, or were most likely to be found in surveys and studies. True, FBOs were not the only groups promoting primary behavioral change, but this was their intervention of choice and they probably helped promote this approach with other groups.

Finally, as behavior has continued to change and HIV infection has continued to decline, the number of religious leaders and groups involved in AIDS prevention has expanded under district Ministry of Health AIDS prevention activities (funded by the World Bank’s STI Project). As a result, there is now a high level of involvement on the part of religious organizations and leaders. How high? By 1995, only two years into the first FBO project, over 2,745 trainers and peer educators as well as 5,629 community volunteers in the Muslim IMAU project had reached 193,955 households and had counseled or sensitized 1,059,439 sexually active people, according to the external evaluation of the USAID-funded project that supported the first FBOs. In the Anglican CHUSA project, the project trained 96 diocesan trainers and 5,702 community health educators and had sensitized 736,218 members of the community, also by 1995. There was also a Catholic-run project.

In 1998, I evaluated HIV decline and behavioral change evidence in Uganda for the World Bank. I reviewed district workplans between 1995-98 and conducted interviews with relevant informants. I estimate that an average of 150 religious leaders (ministers, imams, deacons, elders, etc) were being trained in each of Uganda’s 45 districts per year, resulting in some 6,750 religious leaders trained in HIV/AIDS per year. Even if there may have been over-reporting of training numbers, we can reduce figures by a third and there would still be 4,500 trained per year since 1995. “Training” here refers to religious leaders being educated about AIDS and what they could do to help prevent it, usually in brief workshops. Those trained in this way then function as peer educators and group discussants or leaders, talking to others in their religious group or broader community about AIDS and how to prevent it.

Taken altogether, the foregoing amounts to at least suggestive evidence that religious organizations and other more conservative opinion leaders in Uganda (e.g., school authorities, traditional healers, and local political leaders such as chiefs) that have advocated abstinence and fidelity have had a significant impact on overall infection rate decline.

Senegal

Senegal is another country widely recognized as an AIDS success story. Like Uganda, it was one of the first countries in Africa to acknowledge AIDS and to begin implementing significant AIDS prevention and control programs. According to UNAIDS, Senegal currently has one of the lowest HIV seroprevalence rates in sub-Saharan Africa. Data from antenatal clinics complied by UNAIDS show that HIV infection rates were 1.1% in 1990, and only 0.4% by 1997. A UNAIDS document reports, “In Dakar, the major urban area in Senegal, HIV-1 prevalence among antenatal clinic women has been 1% or less for all years up to 1998.” Prevalence rates range from zero to 0.8% outside Dakar.

As in Uganda, we find evidence of primary behavioral change in Senegal, that is, partner reduction and rise in age of sexual debut. For example, researchers, compared two cross-sectional surveys using standardized questionnaires conducted in 1990-1992 and again in 1994. Even by 1994, “The proportion of men who declared casual sex partners in the past 12 months decreased from 39% to 21% (P = 0.01). Condom use (“ever used) was 3.6% in 1993, almost the same low level as Uganda at that time. In a 1997 UNAIDS survey of women in Dakar, where condom use might be expected to be the highest, 23% of women age 16-50 reported ever using a condom.

According to Demographic and Health surveys, the median age of sexual debut has risen in Senegal, from 16.4 in 1993 to 17.5 in 1997. For age-specific comparisons, median age of debut for females 20-24 rose from 17.5 in 1993 to 18 by 1997. For females age 45-49, debut rose from 15.8 in 1993 to 17 by 1997. DHS data seems lacking for males before 1997, but by 1997 age of debut ranged between 18 and 20, depending on the age group. Many or most countries in east and southern Africa seem to have sexual debut median ages of 15 or less.

As in Uganda, FBOs became involved in HIV/AIDS prevention from early in the epidemic in Senegal. A conservative Muslim organization, Jamra, approached the national AIDS program in 1989 to discuss prevention strategies. Also as in Uganda, there was initial disagreement about the role of FBOs in condom promotion. The government conducted a survey of Muslim and Christian leaders to better define a role for them in AIDS mitigation. The survey found that religious leaders needed and wanted more information about HIV/AIDS, so that they in turn could educate those in the respective religious communities. According to UNAIDS:

In response, educational materials were designed to meet the needs of religious leaders. They focused in part on testimonials from people living with AIDS—the human face of the epidemic, often hidden where prevalence remains low. Training sessions about HIV were organized for Imams and teachers of Arabic, and brochures were produced to help them disseminate information. AIDS became a regular topic in Friday sermons in mosques throughout Senegal, and senior religious figures addressed the issue on television and radio.

A Catholic NGO, SIDA, also became involved in prevention as well as counseling and psychosocial support. In 1996, A meeting on AIDS prevention was held for Christian leaders; every bishop in Senegal attended and consensus was reached that AIDS prevention was an important national priority. The following year, Senegal hosted the First International Colloquium on AIDS and Religion, held in Dakar in late 1997, was attended by some 250 persons from 33 countries, including Muslim, Christian, and Buddhist religious leaders and the ministers of health of five African countries. The impact on Senegalese religious leaders of all faiths seems to have been to empower them “to act freely in the promotion of prevention strategies” Yet there was much to overcome before this was possible. A local researcher notes: