Working with faith-based organizations in HIV/AIDS in sub-saharan Africa

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1 BRIEFING NOTES November 2010 Working with faith-based organizations in HIV/AIDS in sub-saharan Africa, Nuffield Centre for International Health and Development, University of Leeds The HIV/AIDS epidemic has proven to be an increasing health challenge in sub-saharan Africa since its onset three decades ago. Due to the magnitude and impact of the epidemic, many actors, including faith-based organizations (FBOs), have become involved in HIV/AIDS response efforts. Reactions to FBOs response, however, have been both positive and negative. Indeed, many governments and donors are questioning the exact role and impact of FBOs in HIV/AIDS. There is an acknowledged evidence gap about what exactly is the role and impact of FBOs in HIV/AIDS. Despite this gap, however, there is evidence to suggest that FBOs are becoming increasingly influential players in HIV/AIDS-related activities and that there are particular areas in which their impact has been greater. As a result, it is important for governments and donors to recognise how they might work with and support FBOs in this work. This note describes FBOs increasing involvement in HIV/AIDS in sub-saharan Africa, analyses the role and impact of their involvement, and looks at ways in which governments and donors may work with and support FBOs within national HIV/AIDS response efforts. Background HIV/AIDS HIV/AIDS remains a global health problem. It was estimated that there were 33 million people living with HIV and 2.0 million deaths due to AIDS in 2007 [1]. Sub-Saharan Africa is the most heavily affected, accounting for 67% of all infections and 72% of all deaths [1]. The social and economic impacts of the epidemic are huge. Life expectancy has dropped by about 20 years and the loss of large numbers of working age people due to AIDS has caused critical shortages in personnel across all sectors, slowed economic growth, deepened household poverty, and left behind approximately million orphans due to HIV/AIDS deaths [1]. In order to tackle the epidemic and its adverse effects the need for a national response involving actors across all levels is increasingly recognized. National HIV/AIDS Response: The need for collaboration across all levels HIV/AIDS affects individuals and communities in all sectors across all levels of society. A country s HIV/AIDS response is therefore heavily dependent on the mobilization and efforts of a range of individuals, leaders, communities, and organizations. Many governments in sub-saharan Africa recognize the need for collaboration and cooperation across all levels of society in the prevention and mitigation of HIV/AIDS, and many have set up national commissions to coordinate their response. FBOs in particular are often active at all levels of society, reach large numbers of individuals and communities through existing networks, and are highly influential in the communities in which they work [2]. Many governments are therefore recognizing the potential for partnerships with FBOs within their response efforts [2-3]. FBOs & HIV/AIDS In sub-saharan Africa, the prominence of FBOs as health and health care service providers is increasing. Currently, FBOs provide anywhere between 30-70% of all health service provision, and in some areas they are often the sole providers [7]. It is difficult to know the exact extent of FBOs involvement in HIV/AIDS. However FBOs involvement is large and continues to

2 proliferate [7]. In parts of South Africa, for example, over the last decade the faith-based response to HIV/AIDS has grown at a rate of around 200% [7]. FBOs HIV/AIDS response spans across the continuum of prevention and mitigation. Overall, FBOs contribution to prevention has revolved around development issues, such as social service provision and education, and around abstinence and faithfulness as prevention strategies, as opposed to condom promotion [6]. FBOs contribution to HIV/AIDS mitigation includes the care and support for people living with HIV/AIDS (PLWHA), particularly through the provision of anti-retroviral treatments (ARTs) and home-based care services, and care and support for orphans and vulnerable children (OVC) [2, 8]. What is a faith-based organization? The term FBO is often used broadly to encompass any religious institution or organization influenced by faith. FBO is therefore used to refer to a variety of organizations, such as: congregations or houses of worship (churches, mosques, etc.); social service agencies; non-governmental organizations (NGOs) based on faith; charitable or development organizations; missionary organizations; and social-political organizations [4]. They range from small grassroots organizations with limited personnel and simple structures to large national or international organizations with huge networks and personnel, complex structures, and substantial resources [5]. Examples of commonly recognized international faith-based nongovernmental organizations include World Vision, Christian Aid, and Islamic Relief. Not all types of FBOs will be involved in HIV/AIDS prevention and mitigation the involvement of which will often depend on the resources and expertise available, in addition to the individual objectives and commitment of the organization itself. Within overall faith-based HIV/AIDS response efforts Christian FBOs have been much more institutionally active than their Islamic counterparts, although there is evidence to suggest that the situation is changing [6]. The response to FBOs overall HIV/AIDS prevention and mitigation efforts has been mixed [6]. Their HIV/AIDS prevention messages are seen as legitimate methods to prevent the spread of HIV/AIDS, and the care and support they have provided to PLWHA and OVC has alleviated the suffering of many, both physically and spiritually [6]. However, some FBOs rejection of condom use and promotion has often placed them in opposition with other stakeholders who question the efficacy of their approach [6]. Furthermore some FBOs association of HIV/AIDS to individual morality and sin is seen as propagating stigma and discrimination of PLWHA [6, 8]. Within the HIV/AIDS arena, FBOs are seen to be most active in the area of mitigation [6]. Orphans and vulnerable children (OVC) are the primary focus of many, while many are involved in the care of PLWHA at both the home-based and community level [3]. The care and support that FBOs provide is often holistic in nature, focusing on both the physical and spiritual or emotional care of the individual [3]. It is these areas which are usually regarded as the most viable options for further support from government and donors. Many FBOs are also involved in prevention efforts, which often focus exclusively on abstinences and faithfulness as opposed to the promotion of condoms [6]. It is difficult to assess the impact of such strategies, although there is some evidence to suggest that these strategies have proven effective in countries like Senegal and Uganda [2], the latter of which is discussed more in detail below. It is the area of prevention which often remains an obstacle to effective partnerships with FBOs, due to many FBOs continued resistance to the use and promotion of condoms. Despite this, many stakeholders have found ways to work with and support FBOs in their HIV/AIDS-related activities some of which are discussed in further detail below. 2

3 What is the Impact of FBOs on HIV/AIDS? Overall, FBOs are recognized as being in a unique position to influence and support overall HIV/AIDS response efforts. It has been argued [2, 6, 8] that FBOs unique position is due to: The trust and respect they embody from the communities in which they work; Their ability to reach large numbers of people through existing networks; Their regular contact with members and followers, particularly at key life events; Their influence and moral authority over issues closely connected to HIV, such as personal behaviour, beliefs about disease causality and prevention, and rules about sexual activity and family life; Their long tradition of providing care, support, and social services in the communities in which they serve; and Their provision of strength, hope, and support for people in need. As discussed above, the response to FBOs overall HIV/AIDS prevention and mitigation efforts has been mixed and FBOs have at times been seen as both supporting and undermining HIV/AIDS prevention and mitigation efforts. Before working with FBOs it is therefore important for governments and donors to understand the ways in which FBOs might support or hinder overall response efforts. How are FBOs supporting the HIV/AIDS response? There are many instances where FBOs are seen as contributing positively to overall HIV/AIDS response efforts, particularly through their active engagement in HIV/AIDS prevention and mitigation [2-3, 8]. Examples include: The provision of care and support for people living with HIV/AIDS (PLWHA) (ex. clinical care, home-based care, counselling, food and material support, support groups, and spiritual and pastoral care); Support for orphans and vulnerable children; HIV/AIDS prevention and education; Voluntary counselling and testing; HIV/AIDS advocacy; and Internal and external de-stigmatization efforts of PLWHA (training manuals, discussion guides, theological reflections, resource manuals). Not all FBOs working in the area of HIV/AIDS will be involved in all these. Some will be more involved in HIV/AIDS prevention efforts, some almost exclusively in care and treatment, while others will be involved in a combination of the above. What an FBO is involved in will depend on many factors, including the resources and expertise available and the mission and commitment of the organization. Overall, the potential positive contribution of FBOs to overall HIV/AIDS response efforts is increasingly recognized [2, 6]. How are FBOs undermining the HIV/AIDS response? At the same time, some FBOs are seen as obstacles to the reduction and prevention of HIV/AIDS. Some FBOs, for example, have been criticized [2, 6, 8] for: Their delayed response to HIV/AIDS; Their resistance to condom use and promotion; Their reduction of HIV infection to issues of individual morality and sin (resulting in stigmatization and silence); Their failure to engage openly with topics fundamental to HIV/AIDS prevention, such as human sexuality, women s empowerment, and gender relations; Their condemnation of people, particularly women, who engage in sex before marriage, have multiple relationships, or participate in commercial sex work; and Their denial that HIV/AIDS is a problem within their own faith. Not all of the above will be true of all FBOs, and the response of many FBOs has changed over time. Because it is difficult to generalise about the overall response of FBOs to HIV/AIDS it becomes important to assess a FBO s HIV/AIDS response individually. When some of the above do exist, however, how individual stakeholders may be able to work with FBOs in spite of these issue s is discussed bel ow, and is exemplified in the following Ugandan case study. 3

4 The Case of Uganda Throughout the 1990s Uganda witnessed a substantial decline in HIV/AIDS prevalence rates. Between 1992 and 2002 overall HIV prevalence declined from its peak of 18% to 6.1% [9]. Between 1993 and 1999 some urban surveillance sites reported a decline from 30% to 10% in HIV infection, and at the main hospital in Kampala a decline in HIV infection from 44% to 23% was reported [2]. Recent data suggests a stabilization or slight rise in overall HIV prevalence rates [9]. Behaviour change has been argued to be the cause of Uganda s past success [2]. On one side, government policy, political leadership, and the involvement of the international community have been credited with playing an important role in instigating behaviour change. On the other side, the government s efforts to unite the response of the country s HIV/AIDS stakeholders is recognized as helping to instigate such change [2]. In particular, much of the reason for Uganda s success has been credited to the involvement of community-based and non-governmental organizations, including FBOs [2, 10]. It is estimated that in the 1990s, for example, there were over 1,500 registered and un-registered community and non-governmental organizations in Uganda, many of which were religious groups and organizations [2]. HIV/AIDS is a complex issue, and prevention requires behaviour change in a sensitive area sexual behaviour. Most behaviour change messages adopt the ABC approach Abstain, Be faithful, and use a Condom. Due to their religious beliefs, however, many FBOs focus solely on A and B, and often find themselves in opposition with other actors over C. In Uganda the early cooperation and resolution of differences between FBOs and government is credited with its behaviour change success and reduced HIV/AIDS prevalence rates [2]. In this case, the government s and FBOs approaches to behaviour change were pursued on consented parallel tracks with little to no conflict between the two approaches. This is credited with having aided in the creation of culturally appropriate solutions to the HIV/AIDS epidemic, especially in a country where there is considerable resistance to condom usage by a large proportion of the population due to individual religious and cultural beliefs [2, 10]. In addition, the lack of availability and high cost of condoms in many rural areas of the country is said to have made faith-based prevention messages even more appealing [2]. Overall, it is argued that the case of Uganda suggests that faith-based approaches to HIV/AIDS prevention can complement national HIV/AIDS response efforts and that FBOs and other stakeholders can work together to reduce HIV/AIDS prevalence rates [2]. Enhancing FBO involvement in national HIV/AIDS response efforts There is a need for collaboration across all levels in national HIV/AIDS response efforts, and FBOs are in a position to support those efforts. Ways to enhance FBOs participation in HIV/AIDS-related activities at both the local and national level include [3, 5-6]: Assessing overall FBO involvement in HIV/AIDS within country, including types of activities and approaches; Recognizing both the strengths and limitations of FBOs as defined by both FBOs and government, and harnessing their strengths where applicable with regards to national HIV/AIDS strategies; Building the capacity of FBOs to better equip them in their HIV/AIDS-related work by providing financial and technical support; Including FBOs within consultation processes of national HIV/AIDS policies and strategies; and, Entering into discussions with FBOs when approaches to HIV/AIDS differ in order to develop ideas on how the cooperation and/or resolution of differences can be achieved, and how FBOs HIV/AIDS related activities might complement existing national HIV/AIDS strategies, and vice versa. FBOs are highly involved in HIV/AIDS-related activities, however, the potential remains for FBOs to have a greater impact on overall HIV/AIDS response efforts. Effective participation and support of FBOs in HIV/AIDS-related activities would therefore increase FBO involvement and allow them to better support the national HIV/AIDS response [6]. 4

5 Summary HIV/AIDS is a global health challenge, affecting all sectors at all levels of society. There is a need for collaboration across all levels within HIV/AIDS response efforts. The potential for effective partnerships between government and FBOs is increasingly recognized. Overall, FBOs are in a unique position to influence and support HIV/AIDS prevention and mitigation and are becoming increasingly significant players. FBOs are involved in both HIV/AIDS prevention and mitigation but are seen to be most effective in the area of mitigation. The faith-based response to HIV/AIDS is diverse and has been viewed as both undermining and supporting overall response efforts. FBOs HIV/AIDS-related activities have the potential to complement and support existing HIV/AIDS strategies. Increasing the participation and support of FBOs in HIV/AIDS-related activities would ensure FBOs had a greater impact on overall HIV/AIDS response efforts. Key Messages 1. There is a substantial evidence gap on the involvement and impact of FBOs in HIV/AIDS prevention and mitigation at both the local and national level. Further research is needed to better understand FBOs involvement and impact in HIV/AIDS and how FBOs might be used within national response efforts [6]. 2. FBOs have the potential to have a greater impact on overall HIV/AIDS response efforts. Effective participation and support of FBOs in HIV/AIDS-related activities would increase FBO involvement and allow them to better support national HIV/AIDS strategies [6]. 3. FBOs are seen to be most active in the area of HIV/AIDS mitigation, which includes the care and support for people living with HIV/AIDS (PLWHA), particularly through the provision of anti-retroviral treatments (ARTs) and homebased care services, and care and support for orphans and vulnerable children (OVC), but are also highly involved in prevention [6]. 4. When FBOs approaches to HIV/AIDS differ discussions with FBOs can be entered into in order to develop ideas on how the cooperation and/or resolution of differences can be achieved, and how FBOs HIV/AIDS-related activities might complement existing national HIV/AIDS strategies, and vice versa [5-6]. References 1. UNAIDS, Report on the Global AIDS Epidemic UNAIDS, Editor. 2008, Joint United National Programme on HIV/AIDS (UNAIDS): Geneva. 2. Liebowitz, J., The impact of faith-based organizations on HIV/AIDS prevention and mitigation in Africa. 2002, Health Economics and HIV/AIDS Research Division (HEARD), University of Natal. 3. ARHAP, Appreciating Assets: The Contribution of Religion to Universal Access in Africa. 2006, Report for the World Health Organization: Cape Town. 4. Clarke, G., Faith Matters: Faith-Based Organizations, Civil Society and International Development. Journal of International Development, : p Lux, S. and K. Greenaway, Scaling up Effective Partnerships: A guide to working with faith-based organizations in the response to HIV and AIDS. 2006, Ecumenical Advocacy Alliance. 6. Tiendrebeogo, G. and M. Buyckx, Bulletin 361: Faith-Based Organizations and HIV/AIDS Prevention and Impact Mitigation in Africa. 2004, Royal Tropical Institute, KIT Development, Policy and Practice: Amsterdam. 7. Olivier, J., et al., ARHAP Literature Review: Working in a bounded field of unknowing. 2006, African Religious Health Assets Programme: Cape Town. 8. Parker, W. and K. Birdsall, HIV/AIDS, Stigma and Faith-based Organizations: A review. 2005, Developed by Centre for AIDS Development, Research and Evaluation (CADRE) on behalf of Futures Group. 9. GOU, UNGASS Country Progress Report Uganda, January 2008-December , Government of Uganda (GOU). 10. Parkhurst, J.O., The Crisis of AIDS and the Politics of Response: the Case of Uganda. International Relations, (6): p