Faith-based organisations and HIV prevention in Africa: A review

Abstract Background Faith-based organisations (FBOs) are potentially an important role-player in HIV prevention, but there has been little systematic study of their potential strengths and weaknesses in this area. Objectives To identify the strengths and weaknesses of FBOs in terms of HIV prevention. The questions posed were, (1) ‘What is the influence of religion on sexual behaviour in Africa?’, and (2) ‘What are the factors that enable religion to have an influence on sexual behaviour?’.   Method A literature search of Medline, SABINET, Africa Wide NIPAD and Google Scholar was conducted.   Results The potential for Faith-based organisations to be important role-players in HIV prevention is undermined by the church’s difficulties with discussing sexuality, avoiding stigma, gender issues and acceptance of condoms. It appears that, in contrast with high-income countries, religiosity does not have an overall positive impact on risky sexual behaviour in Africa. Churches may, however, have a positive impact on alcohol use and its associated risky behaviour, as well as self-efficacy. The influence of the church on sexual behaviour may also be associated with the degree of social engagement and control within the church culture. Conclusion Faith-based organisations have the potential to be an important role player in terms of HIV prevention. However, in order to be more effective, the church needs to take up the challenge of empowering young women, recognising the need for their sexually-active youth to use protection, reducing judgemental attitudes and changing the didactical methods used.


Introduction Significance
This review highlights the important role of religion in terms of its impact on sexuality.Given the reach of Faith-based organisations (FBOs) in Africa, this review has some important findings with regard to HIV prevention: Religion is so overwhelmingly significant in… African values, attitudes, perspectives and decision-making frameworks that the inability to understand religion leads to an inability to understand people's lives. 1

Aim of the article
Although African Faith-based organisations are recognised as being important role players in the provision of HIV care, there is less evidence of their engagement with HIV prevention programmes or in reducing risky sexual behaviour. 1,2,3The aim of this article is to review the literature in relation to the following three questions: • What are the strengths and weaknesses of FBOs in terms of HIV prevention?

The strengths of Faith-based organisations in HIV prevention work
Faith-based organisations are accessible throughout Africa and extend into the poorest informal settlements and the most remote villages. 3,4,5,6,7Interventions via FBOs are affordable since churches have existing infrastructure and personnel, and church members are often motivated by their faith and are willing to volunteer. 1,6FBOs also have a high level of acceptability, sometimes higher than government or foreign organisations, since they are part of the local culture. 1,3hey are also known for their positive values such as justice, compassion and respect for human dignity. 3FBOs can have a positive role in facilitating behaviour change with a large constituency on a weekly basis, affording opportunities for information-sharing and teaching.Religions uphold the principles surrounding family, marriage and sexuality; promoting abstinence outside of marriage; and fidelity within marriage. 6,7FBOs, therefore, have the potential strength to be key role players in combating the HIV pandemic, but this potential is limited by several weaknesses.

The weaknesses of Faith-based organisations in HIV prevention work
In the early days of HIV in Africa, the Church added to the stigma of those diagnosed with HIV.Many church leaders are not comfortable with speaking openly about sex and give inadequate attention to issues such as domestic violence or sexual coercion. 3,8The church has often ignored the needs of sexually-active adolescents and has enormous issues with the topics of gender and homosexuality. 6FBOs contributed to this stigma since many churches viewed HIV infection as being the consequence of immoral actions.Although the position of the church has changed slowly over the past twenty years, stigmatising attitudes continue at the local level. 3,6Churches have been criticised for patriarchal and hierarchical structures that promote gender inequality. 4,6,7he most highly-publicised negative role of the church is its attitude toward condoms; especially the Roman Catholic and Pentecostal Churches.As a Catholic priest in Kenya said: There is no place in our religion for the use of condoms, whether in the regulation of fertility or in the control of the diseases.And that is the teaching of Christ. 8ny Protestant churches also believe that teaching about condoms would encourage promiscuity.The condom debate tends to focus almost entirely on individual morality, sidelining issues such as socio-economic status, culture and gender relations. 8

The influence of Faith-based organisations on sexual behaviour
Research conducted in high-income countries shows that religious faith plays a role in protecting young people from early sexual activity. 9,10,11,12,13,14,15Religious youths were likely to have fewer sexual partners and to delay sexual initiation. 11,12,15,16,17However, studies also indicate that sexually-active religious youths were less likely to use protection due to the linking of condoms with sin. 13,14,15,16,18hus studies from high-income countries indicate that although religiosity may protect against initiating sexual activity, it may fail to protect against unsafe sex once youths are sexually active.There are a few studies on religiosity and sexual activity from Africa, 19,20,21,22 and the eleven studies found are summarised in Table 1.

Sexual activity
Two studies reported a later age of sexual debut for religious youth, whereas three others showed no impact. 20,22,23,24,27tudies from South Africa and Nigeria found that sexual activity amongst church youth did not appear to differ substantially from that of the local community. 22,23,25,26As these studies are based in different cultural and theological groups, they suggest that the effect of religiosity on sexual behaviour might be less in Africa than in high-income countries.Only one study showed an impact of religiosity on numbers of partners whereas all the others showed no impact. 24Most of the studies showed a reduction in condom use and one study showed no impact. 27

Non-vaginal sex
In South Africa, church youth engage in oral and anal sex in order to maintain a technical virginity. 23,25Because the church often views these subjects as 'taboo' they are possibly exposing youth to risk through a lack of information.

Gender
One study showed higher levels of sexual activity amongst religious girls, as compared with non-religious girls. 22eligious girls may also be at higher risk of HIV infection because they are more likely to see condoms as forbidden by their religion. 21They may also conform to religious teaching to be submissive, finding it harder to either refuse sex or negotiate for condom use.This finding contrasts with studies from high-income countries that show that religiosity can aid in reducing sexual activity amongst girls and could point to lower levels of self-efficacy amongst African women. 21

Sexual coercion
Rates of sexual coercion are high amongst church youth in some of these studies and this is an area of concern since few religious organisations deal with this issue openly. 23,25ese findings suggest that religious people may be at higher risk of contracting HIV, since the protective effect of a raised age of sexual debut may be cancelled out by the negative impact of reduced condom use.The positive effect of religion which was noted in high-income countries appears to be weaker in Africa.

How Faith-based organisations influence sexual behaviour
Several factors determine the extent to which an individual's behaviour is influenced by their religiosity.These include moral and religious teaching, socialisation within the group, level of attendance and commitment to the group. 27,30,31aching on extramarital sex Most religious groups are opposed to premarital and extramarital sex, but messaging varies between groups. 30,32n Zionist and Mainline Churches, the 'approach seems to be that promiscuity is bad, but that abstinence is unrealistic, and that pre-marital sex with one partner is admissible'. 30In contrast, the Pentecostal churches give very clear directives against pre-marital sex: 'The abasindiswa (Pentecostals) don't have sex at all before marriage.But we amakholwa (Mainline) are more realistic, we know that we are human.So we do have our boyfriends, but just one at a time.Non-church goers have as many relationships as they want'. 30

Teaching on condoms
Although Pentecostal and Catholic churches take a stronger stance against condom usage than others, it appears that the official teaching of the Catholic Church is not always adhered to at grassroots level and some priests discuss condom use privately with parisioners. 31In contrast, the Pentecostal church appears to be strictly against condoms, at both official and grassroots levels.Some Pentecostal leaders described condoms as 'satanic' and 'promoters of sin'. 32mongst Mainline churches there is often more openness to the promotion of condoms through the ABC (Abstain, Be faithful, Condomise) message.However, many leaders feel that these are conflicting messages: I find it difficult to tell my members to use Chishango (condoms) should they fail to abstain.I tell someone that doing this is sinning.I have disseminated two different messages at once. 31

Methods of teaching
Current moral teaching does not appear to be effective in leading to behaviour change and churches often address issues of sexuality in didactic and judgemental ways. 6Young people are told to stay away from sex, but are not empowered with the skills to be able to do so.Changing values and behaviour requires interaction, discussion and clarification. 33n order to adopt and internalise new values, interactive dialogical methods of teaching are likely to be more effective.Through participatory educational methods, young people can apply their spiritual values to the area of sexuality as well as develop a critical consciousness around their gender roles that protects them better from unsafe sex. 34

Attitudes to alcohol
Religious groups tend to have more conservative attitudes to alcohol, which may lead to a reduction in levels of unsafe sexual behaviour (as this is often seen to occur under the influence of alcohol). 9,35ilding self-efficacy Religion helps people in their search for meaning and associations have been found between self-efficacy and religiosity. 9,12Self-efficacy can be increased as young people are affirmed and given opportunities for leadership. 36

Social groups
The more deeply involved religion is in daily life, the greater its ability to influence behaviour. 3,30In South Africa, Pentecostal youth meet about five times a week and this group has a strong influence on their attitudes and behaviour, helping them to abide by stricter rules.In contrast, few of the Mainline churches have youth meetings more than once a week: Given the muted religious experience of Mainline Christianity, the absence of youth groups or choirs (socialisation) and the lack of specific teaching on sex-related matters (indoctrination) the influence of these churches on sexual praxis is limited. 30cial capital can be increased as young people become more involved in the church through positive peer pressure and by building relationships with adults who are positive role models. 31,37,38

Social control
Conservative denominations also exercise control over young people's sexual behaviour.In Zambia, the 'New Mission' churches (e.g.Jehovah's Witness, Seventh Day Adventist) had a greater degree of social control than other denominations as those found guilty of premarital sex were removed from membership.Other denominations are more flexible, with doctrines based on repentance and forgiveness. 27,32

Level of commitment
Sexual behaviour is also impacted by a person's level of commitment to their religion. 27,31,39With greater levels of commitment, an individual will receive more frequent religious messages and will socialise with peers with similar attitudes. 40Fatusi's study in Nigeria found that increased attendance at church increased sexual activity, whereas those who attached a higher level of importance to religion had lower rates of sexual activity. 20This could indicate that, in certain communities, attending church is one of the ways to meet sexual partners.Myint's study 41 also indicated that HIV-positive people may attend church more frequently as a source of support.

Limitations of the review
This was an extensive review of the literature as part of a doctoral thesis, however the methodological rigour of a systematic review on one specific research question was not followed.The literature found was very limited and, as a result of its paucity, it was necessary to include studies which were not methodologically of a high standard.For example, details of the methods and outcome measures were often not well defined.Although the literature is reviewed in terms of an African perspective, the huge variety of contexts, cultures and religions within Africa make it difficult to generalise.The findings of this review should therefore be seen as preliminary and tentative.Nevertheless, the review summarises the available literature in an aspect of HIV prevention that is often overlooked from a health perspective.There is a need for further research to explore the suggested trends and associations.The majority of the literature was from the Christian tradition and very little was found from other religious traditions.

Conclusions
In Sub-Saharan Africa, given the church's accessibility, affordability and acceptability, FBOs are potentiallyimportant role players in HIV prevention.However, this potential is undermined by the church's difficulties with discussing sexuality, avoiding the stigma of HIV, promoting gender equality and accepting the use of condoms.
In contrast with high-income countries, preliminary findings suggest that religiosity does not have a positive impact on sexual behaviour in Africa, apart from on the most committed members.In general, church-based youth may be at higher risk than the general population since sexual activity is similar, but they are less likely to use protection.Young women in particular appear to be at risk.The church needs to take up the challenge of empowering young women as well as recognising the need for protection of their sexually-active youth.
Faith-based organisations influence sexual behaviour through their moral and religious teaching, but differ significantly between denominations in the content of the teaching and usually do not engage with effective teaching methods.They may, however, have a positive impact on alcohol use, selfefficacy and peer pressure through social engagement and control.The level of an individual's commitment is also associated with the effect on sexual behaviour.

•
What is the influence of FBOs on sexual behaviour in Africa?•What are the factors that enable FBOs to have an influence on sexual behaviour?
6 search of Medline, SABINET, Africa Wide NIPAD and Google Scholar was conducted using the following key words: religion, faith-based, Christian, Islam, Muslim, HIV prevention, sexual activity, sexual behaviour, condoms, abstinence, Africa and Sub-Saharan Africa.The review included both medical and religious journals, but was limited to literature in English from 1990 onward.FBOs were defined as local religious congregations or religious nonprofit organisations.6

TABLE 1 :
Studies linking religion and sexual behaviour in Africa.30%were sexually active (40% of males, 21% of females) • Only 35% used condoms at sexual debut • 6% were forced to have sex at sexual debut • 33% of sexually active youth had more than four partners • Rates of sexual activity were similar to the general population By the age of 19, 42% of girls and 44% of boys were sexually active • Rates of sexual activity were similar to the general population (65% vs. 63%)• No significant difference in number of partners or abstinence between Pentecostals and Mainline churches • Pentecostals more likely to use a condom than Mainline (p = 0.007) • 12% had been forced to have sex • Agree 'people should wait until they are married to have sex' -80% • Are willing to wait if they haven't yet had sex -79% Source: Literature review.Sources cited individually in Study column can be obtained from http://dx.doi.org/10.4102/phcfm.v5i1.464CI, Confidence interval; OR, Odds ratio.†, Odds ratio (OR) or p-value were not recorded in all cases