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)  This material to be published in Green, Edward C., The AIDS Crisis in Developing Countries (Praeger Publishers, 2003).

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:

During the first stages of the AIDS epidemic the majority of religious (leaders) condemned those infected with the virus, calling the illness a divine curse. This attitude made AIDS shameful and a positive diagnosis difficult. Religion systematically condemned certain modes of prevention as well as certain individual and group behaviour.

A recent LA Times article describes the role of FBOs and religious leaders today:

While the religious leaders insist that they encourage abstinence over the use of condoms, they acknowledge the importance of dispelling myths about the disease, such as the common theory that AIDS is a curse or a punishment by God. 

It may be argued that sexual behavior in Senegal is conservative by general sub-Saharan African standards, therefore perhaps it is pre-existing norms and values rather than the impact of any interventions that have kept infection rates low. Furthermore, widespread male circumcision among Senegalese men certainly helps prevent heterosexual transmission of HIV. It may even be that the presence of HIV-2 limits the spread of HIV-1. But these considerations fail to explain why HIV-1 infection rates have risen in countries neighboring Senegal, countries comparable with regard to the factors just mentioned, including religious profiles. They do not explain why Senegal is unique in West Africa.

It should be noted that both Senegal and Uganda stand out in Africa as countries where governments supported AIDS prevention efforts boldly and strongly, at a relatively early stage. There is agreement in both countries that this support has made a major difference and has allowed prevention programs to have maximum impact. It is probable that one of the factors inhibiting a strong government response to AIDS elsewhere in Africa and beyond is fear of negative reaction from religious authorities. This only strengthens the argument for involving religious leaders and FBOs as early as possible.

At least the argument cannot be made in Senegal that behavioral change, followed by serprevalence stability or decline, was caused by fear, by simply seeing so much death—the argument often made to explain what happened in Uganda—since IV infection rates never exceeded about 1%, one of the lowest in sub-Saharan Africa.

Jamaica

Risk factors are found in Jamaica that would predict relatively high HIV infection rates: an early age of sexual debut (median age of 14 for boys and girls), multiple sexual partners, a robust sex industry linked with tourism, lack of male circumcision, presence of chancroid, age disparity between partners (a pattern of older men having transactional or coerced sex with younger girls), relatively high levels of alcohol and drug use, and related factors such as poverty, labor emigration and male absenteeism, violence, homophobia, and major stigma associated with AIDS. Yet Jamaica has low HIV infection levels by regional standards: 1.6% or lower among the general population in 2000, down from 2% in 1996. This seems to be because of programs of STD case finding and syndromic management (resulting in declining infection rates of virtually all STDs); and behavioral change programs that have resulted in substantial reduction in number of sexual partners, a slight rise in the median age of sexual debut, and—unlike Uganda-- high rates of condom use.

Jamaica is another country where there has been emphasis on promotion of "fidelity" and "abstinence," as well as condoms and treatment of STDs. This has come from the national HIV/AIDS Control program, through its BCC (behavior change and communication) program. Notable among the vehicles for BCC have been schools and FBOs. As in Uganda, Jamaica’s BCC program has emphasized face-to-face approaches and the use of peer educators.

Sexual Behavior Change in Jamaica

Has promotion of "fidelity" and "abstinence" resulted in behavioral change? The causal variables have yet to be sorted out, but a recent national population-based KAP survey of Jamaicans age 15-49 shows that the proportion of both males and females who reported 2 or more partners for the previous 3 month period declined sharply in 2000, compared to 1996. There was significant decrease among all age groups with the exception of females aged 15-19 (4.5% vs. 3.8% existing at time of a 1996 survey).

Furthermore, the median and mean age of sexual debut rose from 13 to 14 for males between 1996 and 2000; it remained 14 for females. Earlier population-based, quantitative evidence showed that 50% of females aged 15-19 had had sexual experience, down from 59% in 1993. Therefore, the age of sexual debut seems to be rising overall since 1993, albeit slightly.

There is also evidence from a recent qualitative study that some young people believed that 15 or 16 is the earliest that Jamaicans should begin to have intercourse. A focus group of "suburban" boys (those from higher-income neighborhoods) believed that age 18-25 is "ideal" for first sexual experience. Yet sexual debut is at an earlier age. This means that there is a gap between beliefs, values and behavior, a gap that FBOs can do even more to focus on in BCC interventions. The same study showed that boys who delayed first intercourse tended to be "raised in a Christian home" suggesting the influence of religion in delay of sexual debut.
 
Community Peer Educators interviewed by a recent USAID evaluation team reported that “mainstream” Jamaican churches have been particularly cooperative in their AIDS education efforts. With some churches, there was resistance at first. But it took only pointing out that members of a particular church were becoming infected with HIV to change these attitudes. The result is that Jamaica has had good, supportive relations between FBOs and national AIDS efforts in both the public or private sector, for many years.

The USAID evaluation team was unable to find direct evidence of any clergy or religious organizations opposing the work of the National AIDS program. There were occasional allegations that fundamentalist or Pentecostal churches criticized the promotion of condoms, but no real evidence of this emerged anywhere. On the contrary, individual clergy and faith-based organizations were cited virtually everywhere as helpful not only in the care, support and counseling of people living with HIV/ or AIDS, but also in AIDS prevention efforts.

It is important to mention that FBOs in Jamaica have been relatively open about condom education and promotion. The government’s condom social marketing program was even able to promote condoms among church groups on several occasions, and it encountered no church opposition to such efforts.  Condom user rates in Jamaica are high by any country’s standards. Over 90% of sex workers regularly use condoms with clients, and some 77% of men, and between 57-79% of women (depending on age group) reported using a condom during their last sexual encounter with a non-regular partner. Even condom use among regular partners is high by international standards, increasing from 47% in 1996 to 52% in 2000, using the same measure: whether or not a condom was used in the last sexual encounter.
 
In sum, Jamaican FBOs have been active in AIDS prevention (as well as in care and support of those already infected), just as we see in Uganda and Senegal, two other countries that have experienced stabilization and even decline of HIV infection levels at the national level.

Conclusion

In view of these findings, as well as the modeling studies cited, it would seem that there ought to be greater equity in resource allocation between HIV/AIDS prevention programs promoting primary behavioral change --such as delay of sexual debut and reduction of number of sex partners--and the far more familiar programs that promote and provide condoms. There should also be more involvement on the part of faith-based organizations, and more AIDS prevention resources allocated to them—not because this is part of any political agenda, but because it works.

Of course, it is very difficult to attribute behavioral change in Uganda, Jamaica or anywhere to any one, or combination of, specific interventions. It is very hard to control for confounding variables. And few studies have looked specifically at the impact of FBOs. Indeed, very few countries have even supported major, national-level faith-based initiatives in AIDS prevention. The contribution of faith-based organizations has therefore not been recognized by national and international HIV/AIDS donor organizations, at least outside the countries discussed here.  Yet there is now enough suggestive evidence to encourage FBOs to play greater roles in HIV/AIDS prevention, and for donor organizations such as USAID, the World Bank and UNAIDS to support more faith-based initiatives.

In conclusion, the following propositions are submitted for consideration and indeed for far more extensive empirical testing:

1. FBOs are best positioned of any group to promote fidelity and abstinence; this is their “comparative advantage.“ The behavioral change results of such efforts are measured as partner reduction and delay of first sexual experience, to use the language of public health.

2. These behavioral changes tend to be overlooked, yet we have highly suggestive evidence from a least three the few countries that have experienced national-level success in reducing HIV infection rates that they do occur when promoted, and that--according to recent modeling studies--such behavioral changes can have major impact on HIV risk reduction.

3. Religious organizations ought to be given more support in doing what they do best, namely promoting fidelity and abstinence. If FBOs also want to promote condom use, so much the better.

4. It is reasonably well-established that consistent condom use protects against HIV transmission, therefore condom use should be promoted. Yet FBOs should not be forced to emphasize or even necessarily include condom promotion in their HIV/AIDS programs. There are enough other organizations in international AIDS prevention already doing this, and there are insufficient programs directed at partner reduction and delay of sexual debut among youth.

5. Until recently, little international funding has gone to FBOs. There have been few evaluations of FBO AIDS prevention programs; existing evaluations results have not been much discussed or well disseminated; and religious organizations tend to be involved in care and support programs more than in HIV/AIDS prevention.  Thus FBOs remain a great untapped potential in the global fight against AIDS. As new FBO programs are initiated, these should be carefully monitored and evaluated for lessons learned.