The Church And HIV/AIDS In Nigeria:
The Case Of Two Dioceses

Emmanuel N. Uwalaka
Saint Louis University

Introduction

   Nigeria has the third largest number of people living with HIV in the world (after South Africa and India) according to UNAIDS. Nigeria’s 2003 HIV sentinel survey put national HIV prevalence at 5%, a rise from 1.8% found in 1991, (UNAIDS 2004:28). Prevalence levels are highest among young people, particularly women aged 20-29 years, (Ibid). Just as it is in many countries in Sub-Saharan Africa prevalence rates vary from region to region and state to state in Nigeria. Figures from the Federal Ministry of Health in 2003 showed prevalence ranging from a low of 2.3% in the Southwest to a high of 7% in the North Central areas. At the state level the variations are even greater. In Osun and Ogun, for example, prevalence among pregnant women was 1.2% and 1.5% respectively, while in Benue it was 9.3% and in Cross River 12%, (Federal Ministry of Health Nigeria, 2003).

   In early 2000, the Federal Government of Nigeria launched the National Action Committee on AIDS (NACA) with emphasis on multi-sectoral approach to AIDS. Membership is comprised of representatives from federal ministries, the private sector, non-governmental organizations (NGOS) and networks of people living with HIV/AIDS, (The Synergy Project 2002:1). State and Local Action Committee on AIDS (SACA and LACA) are also being formed to spearhead the local multi-sectoral response to HIV/AIDS, (ibid.). Prior to the formation of NACA, Nigerian government had vacillated in action and paid lip service to the AIDS epidemic. Despite the fact the first AIDS case in Nigeria was reported in 1986, Nigeria’s first HIV/AIDS Emergency Action Plan was not approved until 2001. While there are plans and discussions at the national and state levels to deal with HIV/AIDS, one institution that is left out of the discussion is the Church.

   The aims and objectives of this study are to systematically examine the role of church organizations in responding to the HIV/AIDS crisis in terms of being involved in prevention, education, and offering compassionate health care to people living with HIV/AIDS. Also, the study examines how one explains approach to HIV/AIDS campaigns.

   According to the most recent survey on religiosity around the world by Gallup International, Nigeria after Ghana has the largest number of people (94% and 96%, respectively) who consider themselves religious, (Gallup International, 2005). Churches have large memberships and according to Lasater, et. al., (1986), “are likely to facilitate widespread diffusion because many members also belong to other organizations throughout the community.” Also, churches are one of the first places many people naturally turn to when problems arise, (Scarlett, 1970). Equally, they are located in almost every community and many have a long-standing history of volunteerism and service to the community, (Lasater, et. al.). On a national level, people have lost faith in their political leaders given the level of corruption, the role of “4-1-9” fraud (named after the section of the Nigerian penal code which addresses fraud schemes), high unemployment rate, the inability of the government to provide security and improve the quality of lives of the average Nigerian. Customarily, when things are hopeless on a national level, people look to traditional institutions for solace. But these institutions have lost legitimacy among the people because of the proliferation of traditional titles. The Church, therefore, remains the only legitimate institution for the majority of Nigerians look to for support.

Literature Review

   For centuries religious organizations have been known for their compassionate health care and spiritual guidance. Their deep historical roots are closely linked to the environment of the people and have effective channels of communication that can be utilized. These groups often are well positioned to access and help vulnerable populations with extensive resources and knowledge, (Walkup, 2002). As 39.4 million people are living with HIV/AIDS in the world and the epidemic is still in the exponential phase in several developing countries, it is no surprise that governments all over the world are seeking help from religious organizations for the fight against HIV/AIDS, (“Global Framework on HIV/AIDS,” 2001).

   Despite the growing interest in involvement of religious leaders and organizations in HIV/AIDS prevention, limited studies have been conducted to demonstrate the effectiveness on the work they do. The scant empirical research mostly focus on the involvement of Faith-Based Organizations (FBO), religious and religious-based organizations, places of religious worship or congregations, specialized religious institutions, and unregistered non-profit institutions that have religious character or missions. The findings of these studies suggest the following elements regarding FBO HIV/AIDS prevention programs: ability to provide positive values to the community, health behavior change, and supportive social relationships, (Breger et al., 2001).

   Faith-based organizations promote physical and mental health for the community, as well as providing spiritual needs of the congregation. In Nigerian society FBOs serve as advocates, supporters, and enablers of actions for advancement in the community.

   A study by Jordan Smith (2004), among Nigerians illustrated that religion plays a major role in their belief and practices. In this study, 863 Nigerians were interviewed, of which 70% of them were Christians and 30% belonged to Pentecostal and evangelical churches. The results of this study showed that majority of the participants were being taught about HIV/AIDS related risks at churches during sermons. Most of the participants believed that HIV/AIDS is the result of immorality and can be prevented by being a good, moral Christian. Abstinence and moral partnering were thought to be best prevention mechanisms for HIV/AIDS by many subjects.

   Another study by Elifson, et. al. (2003), showed that religiosity is a strong predictor of women’s involvement in HIV-related risky behaviors. This questionnaire-based study was done on 250 women who were above the age 18 years residing in Atlanta between 1997 and 2000. Religiosity was measured using three variables: how frequently the person attended worship services during the past year, how strongly they felt about religious beliefs, and an interaction term combining the two variables. HIV-related risky behavior was assessed through three main factors: multiple partners, injection drug use, and anonymous sex. The results showed that religion is a strong predictor of women’s involvement in HIV-related risky behaviors, even when accounted for confounding variables (demographics, childhood maltreatment, substance abuse, and condom related beliefs). The study showed that the more frequent the women attended worship services the less involved they tended to be in HIV-related risky behaviors, (ibid:58-59).

   The finding from both studies are similar in suggesting that FBOs are able to play an important role in helping individuals reduce their involvement in HIV risk behaviors. Since these organizations are often highly trusted and greatly relied upon by the people they serve, they are promising avenues for educating people about HIV risks and providing them with needed support services, referrals, and intervention activities.

   Health behavior changes have resulted from health promotion interventions conducted in churches. FBOs have been found to positively influence behavior change in studies promoting a variety of health behaviors. A study by Marcus, et. al. (2004), demonstrated that a FBO intervention program significantly heightened the fear of AIDS. The intervention program, named Project Bridge, aimed to reduce substance abuse and HIV/AIDS among African-American adolescents. Program Bridge provided scripture and moral teachings for three years to 34 adolescents between 13 and 14 years of age. When the intervention group was compared to 27 adolescents in the control group, the analysis showed the subjects in the intervention group (100%) were more afraid of getting AIDS than the control group (90.2%) and reported compassion for those living with AIDS (chi² = 5.28; p = 0.071). Furthermore, the study showed that the Bridge-participants went on to teach about HIV/AIDS at their schools. This verifies that faith-based prevention programs can produce a positive effect on participants.

   Chronic illness, such as HIV/AIDS, places stress on an individual’s mental health and affects their social support, coping, and overall health status. Recent studies have shown that people living with HIV/AIDS seek social support from their religious organizations by participating in prayer practices and formal religious activities than their non-infected counterparts. Churches also help to reduce and provide solace from the prejudice and shame many living with HIV/AIDS may face, (“Global Framework on HIV/AIDS,” 2001). Somlai and his colleagues have demonstrated a relationship between social support and life satisfaction with higher levels of spirituality. In this study of 275 HIV-infected people, they showed that subjects who engaged in more frequent religious practices reported decreased level of HIV-related symptoms, obtained greater support from their family, and were less likely to have multiple partners. These findings illustrate that religion can be a social, mental, and physical healing aspect for HIV-infected individuals, (Somlai and Heckman, 2000).

   Although most FBOs are either still in the formative state or in the process of carrying out HIV/AIDS prevention programs on a limited scale, their self-initiative, their knowledge of and acceptance by the community, and their relative cost-effectiveness render them owners, advocates and participants in prevention programs for HIV/AIDS. FBOs are assisting the people living with HIV/AIDS by providing financial assistance for medical treatments, food to increase their nutritional status, home-based care by other members of the congregation, and counseling, (“Global Framework on HIV/AIDS,” 2001).

   Lynn, et.al. (1988) demonstrated that FBOs are excellent vehicles to provide health care for people in low-income and underserved areas, where people distrust professionals and official agencies. The study was done in 176 inner-city churches in America. All the churches in the study were located in areas with high rate of unemployment, teenage pregnancy, gang crime, and hunger. The spokesperson for each church was interviewed about the problems facing their community and the number of programs the church is providing to reduce the issues. The analysis showed high association between churches and the number of healthcare programs geared to facilitate the particular community. The churches placed high priority on the most immediate problems and focused their programs according to the availability of funding,

   Another advantage to FBO-healthcare programs is the reduced need for funds. Since most of the assistance is provided voluntarily by the congregation, FBOs can facilitate a larger population and channel it in a method familiar to its people, (Walkup, 2005).

   A Global Assessment of Faith-based Organization’s Access to Resources of HIV and AIDS Responses (2005) demonstrated that though FBOs are substantially trying to fill the gaps of government-based HIV/AIDS programs, they lack capacity, information, and interaction with other organizations. The survey showed that FBOs, especially in developing countries, do not have sufficient knowledge in areas of proposal writing, management of large-scale projects, implementation of projects, and evaluations of key areas. These factors are affecting funding from big donors.

Methodology

   Data for this study was collected between September and November 2004 during my sabbatical leave in Nigeria. Given the time and cost involved, two dioceses, namely, the Archdiocese of Owerri, the capital of the Imo state of Nigeria and Ahiara were studied. Thirty organizations as listed in each of the dioceses directory of events were identified. Twenty were randomly selected. Using a disproportionate stratified sampling method, forty-four organization leaders were selected. A questionnaire containing fifty-two questions was given to each organization leader. The questionnaire was hand-delivered either at the office, home, or church event. The questions were aimed to tap into subjects’ demography, knowledge, beliefs, HIV/AIDS activities (in terms of raising awareness, education, prevention, assistance to people living with AIDS, and dealing with stigma and discrimination.

Findings

   The sample consisted of 26 males (59.1%) and 18 females (40.9%) with a mean age of 45.73 and a standard deviation of 15.5. Twenty respondents (45.5%) are married, 21 respondents (47.7%) never married, and 1 respondent (2.3%) separated. A majority of the respondents, 38 (86.4%) are Catholic, 3 (6.8%) Protestant, and 3 (6.8%) some other religion. Also, a majority of the respondents, 40 (90.9%) attend religious services at least once a week and 4 (9.1%) at least once in a month. On media use, 12 (27.3%) identify newspaper as major source of news about HIV/AIDS as against 8 (18.2%) for television, 11 (25%) radio, 2 (4.5%) friend/relatives, and 9 (20.5%) medical. On the average, respondents read newspapers and watch television news two days per week. A majority of respondents answered, “yes” to the question “Does the church have a governing board?” 86.4% vs. (2.3%) who answered “no.” Also, most of the churches, 40 (90.9%), have community health programs versus 1(2.3%) that does not. Finally, the frequency of church collaboration with other organizations such as neighborhood associations, hospitals, health departments, local doctors or medical clinics, or other churches had varying responses. The responses were: “2-5 occasions per year” and “more often than monthly” 11 (25%) and 5 (11.4%) respectively, “every other month,” 4 (9.1%) “monthly,” 2 (4.5%) “once a year,” and 1 (2.3%) “never.”

   The frequency distributions on knowledge questions showed some interesting results. The first question asked, “Being around someone with AIDS would not put my health in danger?” More than half of the respondents (52.3%) answered, “agree strongly.” On the question “I would comfortably discuss AIDS with others, almost all the respondents (93%) answered, “agree strongly.”

   Several questions were designed to tap into respondents’ misconceptions about AIDS. In order to carry out any meaningful and effective HIV/AIDS intervention programs, one has to break down misconceptions about the disease. The respondents showed no incorrect beliefs about AIDS. Some of the responses were as follows: “You can get AIDS from sharing a common communion cup?” Thirty- five (79.5%) of the respondents said no. “You can get AIDS from sitting on a toilet seat?” The response was (72.7%) no. “You can get AIDS by drinking from the same glass as someone who has AIDS?” an overwhelming majority (63.6%) said no, as against $18.2%) who said “yes.”

   Stigma is a “mark” or “blemish” upon someone or something (www.measuredhs.com/hivdata/prog_detl.cfm?prog_area?id=3). Social attitudes may be damaging to those infected or suspected of being infected, (ibid). In many Nigerian societies, HIV is often negatively viewed, and those carrying the disease are regarded as outcasts. Fighting against discrimination is upholding the constitutional rights of people living with HIV/AIDS not to face inhuman and degrading treatment.

   Stigma and discrimination are of concern to AIDS programs for the following reasons. Firstly, life becomes difficult for those with the disease. Secondly, after diagnosis infected patients may leave care and possibly spread the disease. These facts were confirmed during an interview with a nun in charge of a rural maternity hospital. She detailed instances of women and men after diagnosis never returning. Eventually, such people would go about spreading the disease. Another was a thirty-five year old unmarried lady, who when told she tested positive committed suicide. One might think institutions of higher learning would not be culpable of discrimination. But this was not the case, when a prospective journalism student’s letter of admission was rescinded, because the Institute learned he was living with HIV. The fact is that stigma and discrimination will complicate AIDS prevention efforts.

   In order to tap into respondents’ attitudes on stigma we asked the following questions: (1) “Would you be willing to take care of AIDS patients?” (2) “If you have a relative who has AIDS, would you be willing to look after him?” (3) “Would you be willing to take AIDS tests?” and (4) “Would you want your family to know the results in case your test is HIV positive?” Respondents showed accepting attitudes on all the four questions. Results were twenty-two (50%) “very willing” versus 14 (31.8%) that are “somewhat willing” to take care of AIDS patients, 33 (75%) “very willing” versus 10 (22.7%) “somewhat willing” to look after a relative who has AIDS, 35 (79.5%) “very willing” versus 7 (15.9%) “somewhat willing” to take AIDS test; and 29 (65.9%) “very willing” versus 7 (15.9%) that are “somewhat willing” for family member to know HIV test results.

   Five questions were designed to elicit opinions on respondents’ opinions on beliefs regarding HIV/AIDS. The first question asked whether “Employers should be able to fire someone with AIDS?” A majority of the respondents (63.6%) say they “disagree strongly” as against those who say they “disagree somewhat” (22.7%). This finding is important in mobilizing support at the local and national levels to deal with discriminative practices at the job places and protect workers rights.

   The second question on beliefs regarding HIV/AIDS asked, “AIDS is a curse for one’s sins?” A majority of the respondents (59.1%) say they “disagree strongly.” The response here is significant because it debunks the argument that “one of the major reasons that has contributed to the Church’s slow reaction to the epidemic was the belief that AIDS was God’s punishment for being promiscuous and of loose morals,” (Shoko, 2004). The response puts the challenge on the Church to take the leadership role and be proactive in dealing with stigma and discrimination by shattering the “conspiracy of silence” for which it was accused of in the early stages of HIV/AIDS in Nigeria.

   The fourth question asked, “HIV/AIDS education must be taught in schools.” An overwhelming number of the respondents (88.6%) say they “agree strongly.” The writer has some misgivings about this response. The reason stems from the fact that in many homes and schools it is a taboo to talk about sex. Since one of the major sources of AIDS transmission is sexual contact, there is no general strategy for sex education. Programs geared toward educating and preventing HIV/AIDS through sexual contact face challenges over terminology. The preferred term in the school curricula at the basic and secondary school levels is “Family Life Education.” Ohiri-Aniehe and Odukoya also reports that “Although a reasonable amount of literature exists on HIV/AIDS in Nigeria, relatively little deals specifically with education.” (2004:2)

   The fifth and final question on beliefs regarding HIV/AIDS asked, “Where do you stand on the ‘ABC’ method of HIV/AIDS prevention?” ABC stands for Abstinence, Be Faithful, or Use Condoms if A and B fail. This method has been touted by religious leaders, and the Bush administration as having been effective in reducing infection rate in Uganda. Green (2001) in his evaluation of HIV prevention programs in Uganda and Jamaica, and a study of behavioral change in the Dominican Republic found there were behavioral changes compatible with ABC strategy. There were varying responses to the question. Twenty (45.5%) of the respondents believe in A and B of ABC strategy. Ten (22.7%) say ABC is a good strategy, but has limitations. Five (11.4%) say ABC is a good strategy, 4 (9.1%) only believe in B of ABC strategy, 1 (2.3%) only believe in A of the ABC strategy, and 2 (4.5%) see “ABC” as a bad strategy. The responses here are important because AIDS programs can be targeted to the appropriate population to promote mutual monogamy among sexually active adults or delaying age at first sex, all of which can reduce infection rates.

   The very low response in this study for “abstinence” (A) by itself as the only option is of great concern. The reason is because of the heavy emphasis by the church leaders to promote abstinence in persons unmarried. Sexual intercourse with an infected individual is the primary mode of HIV transmission in Nigeria. The goal of the “ABC” approach is to reduce the spread of HIV. The challenge to the Church is how to achieve this goal given other factors that militate against the “ABC” approach, namely, the abject poverty that flies in the face of any meaningful preventive program, the culture of silence over sex education by church leaders and a number of socio-cultural attitudes and practices with regard to male/female relationship. To achieve any meaningful influence on the behavior and values of Nigerians, all these factors must be addressed if HIV/AIDS could be eradicated in our society, (Catholic Diocese of Ahiara, Mbaise, 2004:2).

HIV/AIDS Prevention and Care Policy

   HIV/AIDS prevention and care policy in the two dioceses studied can be explained by what Butler (2005) terms the ameliorative paradigm as against a “mobilization/biomedical” paradigm. The ameliorative paradigm assumes that a focus on poverty, individual responsibility, palliative care, traditional medicine, and appropriate nutrition are vital in managing the disease. The “mobilization/biomedical” paradigm emphasizes society-wide mobilization, political will, and anti-retroviral (ARV) treatments, (Butler 2005, 592). This second policy prescription is not adopted because it is not feasible. At the national, state, and local levels of government, the political will to deal squarely with the AIDS epidemic is lacking. Government leaders have not been able to match their rhetoric with deeds. Funding for HIV/AIDS can be said to be mediocre to non-existent. Anti-retroviral drugs are not available beyond the capital of the state, where only those who can afford to pay an average of N10,000.00 (ten thousand Naira) or more can get it for just a month. Even where the drugs are available the supply is piece-meal and such an approach does not measure up to sustainable healthcare.

   The ameliorative model has gained ascendancy over the mobilization/biomedical because people are making due with what they have given the exigencies of the time. There is abject poverty everywhere. In my conversation with a leader of a church on what he is doing as the leader of his church in relation to HIV/AIDS, he answered: “Emmanuel, poverty is the problem with my people, not HIV/AIDS. Give them food, and they will be alright.” Also, the coordinator of Action for Health, a non-governmental organization (NGO) that targets students in tertiary institutions with a focus on prevention education, Voluntary Counseling and Confirmatory Testing (VCCT) and referrals had this to say, “The mass poverty and hunger that is very prevalent in the society and more among students still diminish the sense of urgency the fight demands. As some of the students will say, “A hungry man cannot appreciate the danger posed by AIDS. The hunger is a more potent and immediate danger,”. However, these statements, do not deny the fact according to Butler that “poverty is a major, if not the major, deep causal factor for the scale of the African AIDS epidemic,” (2000:2). Poverty by itself is neither necessary nor sufficient for an individual to contract HIV. Faced with the enduring crisis of poverty, lack of funding from governments, national, state, or local, church leaders make do with what they do best, “helping souls” – a characteristic of Ignatian spirituality, which not only looks at the spiritual needs but, also the physical needs of AIDS sufferers.

Contrasting the Two Dioceses of Study

   In contrasting the two dioceses studied, one sees a demonstration of leadership, or call it political will, in facing to the challenge of HIV/AIDS. Following directives from the Catholic Secretariat at Lagos, all dioceses were to adopt a multi-sectoral approach based on the national framework for dealing with HIV/AIDS crisis in Nigeria. Up until November 2004, the fight against the AIDS epidemic had been unsystematic and ad hoc in nature. Care for AIDS patients were mainly by a few NGOs and at some Catholic hospitals. My contacts with the Archdiocese demonstrated a complete absence of any institutional structure to deal with HIV/AIDS. I had earlier been told that poverty was the main problem, not AIDS.

   Unlike the Archdiocese, the leadership of Ahiara diocese has demonstrated an understanding and genuine commitment of the magnitude of the epidemic. On November 8, 2004, His Lordship inaugurated the Parish Action Committee on AIDS (PACA). In his homily, His Lordship alluded to the fact that 12-13 years ago, he toured his diocese and showed videos on AIDS. People did not believe, but at the moment “AIDS is a reality and there is no cure.” Several times he used the Igbo name for AIDS, “oria o biri n’aja ocha” (the disease that ends up in death). Some scholars see this term as intimidating and prefer oria nminwu (a disease that is chronic and debilitating). The first group, a Parish Action Committee AIDS (PACA) was launched this same day. Eventually, all parishes will have their committees on AIDS. The job of the Diocesan Action Committee on AIDS, a committee appointed a year earlier, is to train members of the parish committees who will equally go about in their parishes to raise HIV/AIDS awareness. Their work is purely voluntary.

   It was of great interest to learn of the achievements of the Diocesan Action committee on AIDS barely one year after its appointment. Through its intervention strategy targeted on youths and women, seminars to educate and raise awareness were conducted among youths and staff in about twenty schools and youth groups totally about 14,000. The coordinator of DACA (Diocesan Action Committee on AIDS) to dissipate the myth that HIV/AIDS is found only in major cities, during the inauguration gave statistics from five small hospitals in the diocese, about 186 from 2002 to 2004. According to the coordinator, this number was for the ones who came to the hospitals. According to the coordinator,

“These people are living among us unknown to us and they will continue to conceal it for fear of rejection, discrimination, stigmatization, abandonment, and violence by the family and community. As they conceal it, HIV disease continues to spread.” (HIV/AIDS Awareness Commission 2004).

   The leadership demonstrated by the head of Ahiara diocese is better expressed in the words of his coordinator who ended her remarks at the inauguration by saying, “Let me use this opportunity to express our gratitude to His Lordship for being one of the few bishops from the Eastern part of the country that show much interest and zeal in the health care of his flock. He has always encouraged and supported us and financed all the workshops I have attended, since this committee has no take-off-grant as such,” (ibid).

Limitations of Study

   This study is limited because the findings are based on a small sample. The sample does not allow the application of correlational analysis to establish any significant relationships among the variables. Also, the sample does not allow for the generalization of the findings to all the religious organizations in the dioceses studied.

   Despite these limitations, this study is important because it adds to the literature on the role of religious organizations in terms of their knowledge regarding HIV/AIDS, the issue of stigma and discrimination, and beliefs. A “snapshot” of their opinions on these issues is important if effective programs are to be initiated to confront HIV/AIDS in Nigeria. The leaders of these organizations are motivators and opinion molders within their organizations and the community. The multi-sectoral approach for combating HIV/AIDS in Nigeria calls for the involvement of all levels of government, departments of government, members of civil-society, NGOs, churches, communities, and families. As a result, an “army” of volunteers is needed so that the various activities of the parish action committees on AIDS can be carried out effectively. Also, messages on HIV/AIDS awareness campaigns must be adapted to the target audience with the right language. The writer has been present at masses where more than half of a homily was delivered in English. The result is that the message becomes impersonal, vague, and misses its mark on the larger population that cannot read and write.

   Finally, it must be pointed out that the two dioceses studied face general challenges. The Ahiara diocese has established the basic infrastructure in dealing with HIV/AIDS epidemic. There is commitment by the leadership, the diocesan committee on AIDS has an office at the Catholic Secretariat where they monitor and coordinate the activities of the Parish Action Committees. The Owerri Archdiocese needs to move away from the “freelance” approach in which the epidemic is being handled. Both dioceses need support of all kinds to sustain the HIV/AIDS activities taking place.

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