Medical Examiner

Good News on AIDS in Africa

Deaths are down, and the heroes of the story aren’t who you think.

Worshippers of Shauri Moyo Baptist church in the town of Kisumu make special prayers November 2, 2008 for US Democratic presidential hopeful Barack Obama.
Approximately 90 percent of Africans are regular participants in a religious congregation. Above, a Baptist church in Kenya.

Photo by Tony Karumba/AFP/Getty Images

The latest news on AIDS in sub-Saharan Africa, the epidemic’s epicenter, is good. New HIV infections have declined by 25 percent since 2001, AIDS-related deaths have decreased by 32 percent over the past 6 years, and there are expanded options for testing and treatment. After decades of doom-and-gloom news about AIDS in Africa, optimism is finally in the air.

What’s behind this positive turn? The standard narrative attributes these recent improvements to Western engagement. The heroes are the best-known acronyms in the world of AIDS (PEPFAR, UNAIDS, WHO), the Global Fund, and a host of NGOs. Together, these organizations have waged total war against AIDS in Africa—or what looks like total war if you compare it to efforts devoted to other diseases. They have spent tens of billions of dollars. They have mobilized legions of scientists, medical professionals, development workers, educators, TV programmers, marketing specialists, and volunteers. And they have shunned, silenced, and demonized those who oppose their good work. The good news about AIDS in Africa—so this standard narrative goes—is the result of their efforts. It’s proof that even on that dark and desperate continent, awash with ancient superstitions, hypersexuality, dangerous traditional practices, and poor leadership, AIDS cannot withstand a sustained pummeling by well-intentioned and well-financed outsiders.

This narrative contains some important elements of truth: Pharmacological treatments in particular are transforming HIV from a death sentence into a manageable, chronic condition, at least for those with access to antiretrovirals. But most of the measured improvements in AIDS in Africa are actually the result of cumulative, widespread behavior change that has led to a reduction in new HIV infections. In other words, the standard narrative is wrong.

The narrative is wrong because it ignores local African responses to AIDS and characterizes religion and religious leaders as part of the problem. We have systematically studied the role of religious leaders in sub-Saharan Africa for about a decade. As a single class of people, local religious leaders sit at the very top of our list of who should receive credit for the behavior changes that have curbed the spread of HIV in Africa.

This statement may surprise or even irritate people imagining fire-and-brimstone preachers who condemn the use of condoms, push conservative messages about sex and morality, and interpret AIDS as God’s wrath. That’s not what African religious leaders have been doing—quite the contrary. Yet their story remains untold.

Approximately 90 percent of Africans participate regularly in some religious congregation, and religious leaders have been preaching about sexual morality, in particular about abstinence and fidelity. But Africa’s religious leaders began doing this before PEPFAR and Western public health authorities told them to—long before the attention of the development world turned to AIDS in Africa. What prompted their efforts? Certainly not the fact that they were, or are, getting paid to do this by foreign NGOs. Ninety percent of congregation leaders in Malawi, where we began working on AIDS in 2004, have never seen a penny from any international NGO or their programs. Rather, they started preaching and teaching and facilitating conversations about AIDS when they became overwhelmed with caregiving and burial responsibilities, and when their members—especially the women—began demanding that they do so.

Local religious messages about abstinence and faithfulness are, at their root, moral messages, but not exclusively so. For nearly two decades, religious leaders of various stripes in Malawi—a religiously diverse country with high HIV prevalence—have been offering practical messages about how to resist the temptation of beautiful women, how to prevent jealousies in polygynous households, how to discern whether a boyfriend or girlfriend will be a faithful spouse in the long run, and why withholding sex within marriage might be risky for both partners. These messages have mattered. In congregations where AIDS and sexual mortality are discussed regularly, unmarried people are more likely to report being abstinent and married individuals faithful to their spouses.

At first, we worried that reporting bias (people wanting to appear good and consistent to interviewers asking invasive questions about religion, sexual behavior, etc.) could be driving this pattern. But when tested the responses against both more subjective and more objective criteria, the story checked out: Members of these congregations are less worried about AIDS (a good indicator that they aren’t exposing themselves to much risk), and they’re less likely to test positive for HIV. Far from pushing fire-and-brimstone doctrine, religious messages about abstinence and faithfulness have been pragmatic and effective. They have reduced the spread of HIV in countless African communities that have been unreached by resources from the Global Fund and its counterparts.

In addition to pushing ideas about sexual morality that have roots (even if shallow ones) in religious texts, religious leaders have been promoting innovations to prevent the spread of HIV. These stories, too, have gone untold—unacknowledged by the scientific literature and Western press. We have to wonder why, because condoms, divorce, and booze often make for excellent stories.

On condoms—the public health buff’s favorite subject—religious leaders have been taking pragmatic positions. Most support the use of condoms to prevent HIV transmission. In the late 1980s, a Catholic priest in Tanzania, Father Bernard Joinet, designed a prevention campaign that used images of lifeboats in a sea of AIDS, including one (rubber) boat labeled “condom.” With the support of many religious leaders and organizations, including the Islamic Medical Association of Uganda, this balanced and pragmatic message quickly diffused throughout East Africa.

Of course, support for condoms doesn’t mean that religious leaders are excitedly doling out condoms after communion. They are simply resigned to condoms as a lesser evil. At the same time, they criticize what they see as an obsessive focus on condom promotion on simple pragmatic grounds. First, condom-sex isn’t sustainable in real relationships where there is a desire to procreate. (Childbearing remains important in Africa!) A second factor is pleasure. Said one of the many people we interviewed: “Sex with a condom is like eating a banana with the peel still on it. I’ve never liked those gadgets.” This is why most of the more than 200 religious leaders we interviewed think that condoms are not a sustainable way for couples to live their lives, navigate their relationships, and fully enjoy sex. With regrets to the Vatican and to its critics, low levels of condom use across Africa have little to do with official church teachings. When it comes to AIDS in contemporary Africa, official positions have taken a back seat to pragmatic ideas about how to avoid infection.

This pragmatism is evident in messages about alternative prevention strategies—many of which are endorsed by religious leaders. We frequently found religious leaders articulating new ways to navigate risky relationships, especially risky marriages, where one partner (imagine a careless, womanizing husband) is putting the other (stereotypically, a woman) at risk. In Malawi, we have documented a liberalization of attitudes toward divorce that, importantly, is specific to AIDS. Female-initiated divorce is not just tolerated under these circumstances—it is actively supported. Religious communities have been economically and emotionally supporting women who leave philandering husbands to protect themselves and to reduce the chance of their children being orphaned. New vocabulary for a religiously just divorce has emerged as AIDS has spread. Women have been using these ideas to pressure their husbands to change their ways and to kick out dangerous husbands (“Take your mat and go!” as our colleague Enid Schatz has described it) while leaving their own reputations intact.

Another example is related to religious prohibitions against alcohol consumption. Religious leaders from historically imbibing traditions have begun to preach about abstaining from alcohol, and many from historically teetotaling traditions have intensified their message. They have also begun to police members’ drinking. To Western ears this sounds like an effort to exert quasi-inquisitional religious authority over individuals. But understand the context. Many of us drink in the comfort of our own homes (often accompanied by our loving partners). But consumption of alcohol across Africa tends to be more public and to occur in places that provide opportunities for unsafe sex: Women working at bars and bottle shops often double as prostitutes. So the religious leaders we interviewed not only preach against drinking and drunkenness, they also patrol local bars to deter members from wandering down a road that might lead to temptation and compromised decision-making. This is true not only of Christians. At the behest of his female congregants, one of our favorite imams camps out each evening at the trading center to send thirsty male Muslims safely home to their wives before they even have the chance to make a bad choice.

There is a more empirically accurate narrative about religion and AIDS in Africa, and we’ve described it at length in our recent book Religion and AIDS in Africa. There is no ambiguity in the data: Religion has been central to curbing the spread of HIV in local communities across sub-Saharan Africa. Measurable changes and improvements were detectable before PEPFAR and Gates dollars started rolling in. This leaves the puzzle of why this story has remained untold for so long while atypical stories of religious leaders pushing abstinence and burning condoms continue to circulate widely.

Is this just a typical misrepresentation of Africa? That seems a plausible explanation. With some exceptions, journalistic coverage of Africa tends to be flawed, especially when it deals with religion. Favored topics are religious superstitions, leaders’ malfeasance, and poverty-porn featuring witchcraft. Since we can’t get into the heads of Western journalists on the Africa beat or their editors, we make no assumptions about the underlying motives here. But it is 2013, and the West is still in the thrall of the outdated assumption that societies need to jettison old superstitions (religion in particular) in order to modernize. More troubling, Westerners have a hard time seeing anything uniquely African as a positive source of change.

There’s a more general problem, neatly captured in Binyavanga Wainaina’s amusing piece for Granta called “How to Write About Africa.” In the standard narrative, ignorant or aimless Africans passively await guidance and assistance from plucky Westerners who ride in to help—often to intense applause. (Think of Nick Kristof’s regular columns praising earnest American volunteers.) Like Wainaina, we read such stories cautiously and suspiciously. Beyond being mildly offensive, these narratives simply don’t fit the Africa we know—a place, like any other, in which people converse about and respond to AIDS, famine, war, and plain-old daily hardships in contested and complex ways. On the world’s most religious continent, people use religious ideas, language, and organizations to address problems, big and small. This is the source of religion’s positive contribution to the recent improvements in Africa’s AIDS situation. Such stories need to be told.