Involving religious leaders can undermine HIV prevention

Traditionally, international HIV prevention efforts are managed by secular public health organisations or programmes, often internationally funded, that work with local health care providers, statutory organisations, and communities. In the early 2000s, UNICEF introduced a new initiative through which local religious leaders in South Asia, with little or no previous knowledge of HIV, would be invited to join their countries’ HIV prevention efforts. The initiative recognised that religious leaders have great influence on public opinion and people’s behaviour and hoped that through their involvement, these religious leaders would come to adopt a scientific approach to HIV and disseminate appropriate information in their communities.

But a recent paper published in Anthropology and Medicine, drawing on ethnographic research conducted at Pakistan’s National AIDS Control Programme (NACP) from 2010-2012, shows that this initiative backfired when adopted in Pakistan. There, HIV programmes became dominated by conservative religious approaches to HIV, which stigmatised and condemned people living with HIV and cast the HIV epidemic as a moral problem, rather than by the more public-health oriented approach that the programmes expected these religious leaders to adopt.

This shift was not due to religious leaders’ unilaterally imposing their views on NACP staff involved in the initiative. Rather, religious leaders’ conservative views about sexuality, gender and same-sex relations legitimised these staff members’ own biases about people living with or at risk of HIV. These biases were similar to those embedded in religious leaders’ conservative morality but were expressed in more secular terms. The involvement of religious leaders encouraged NACP staff to be more open about their own biases. As a result, conservative religious beliefs that exclude, marginalise, and stigmatise people living with HIV became more entrenched in HIV programmes’ local culture, conversations, and policy documents.

“Instead of dialogue and negotiation in line with the secular ideal of development, the moral authority of the religious figure compelled others to forefront the conservative in them, thereby undermining the goal of HIV prevention in the country,” writes Dr Ayaz Qureshi of the University of Edinburgh.

Religious involvement in HIV prevention

In 2003, a UNICEF working paper recommended that faith leaders be involved in HIV programmes in South Asia, noting that an unexpected number of religious leaders of different faiths across South Asia had expressed a strong interest in learning about HIV prevention and supporting people affected by HIV. The paper identified Thailand and Uganda, where religious leaders had engaged in similar activities, as success stories and models for South Asian countries. The paper also argued that HIV experts could and should teach religious leaders about HIV’s medical and social causes, and that this scientific approach could work alongside, rather than against, these leaders’ moral beliefs, bringing a scientific rationality to their messages about HIV and HIV prevention.

Religious leaders and faith-based organisations have similarly been involved in a range of global health initiatives (for example, family planning and blood donation), as well as other development initiatives (for example, microfinance and women’s empowerment).  

In 2004, this approach to HIV efforts was formalised by the Pakistani government, which launched a Religious Leaders Initiative for HIV and AIDS. This was registered as an NGO (as the ‘Inter-Religious Council on HIV/AIDS’), but the words ‘HIV/AIDS’ were later removed, with the NGO becoming the Inter-Religious Council on Health. By the time Qureshi began his field research at NACP, the Religious Council project was no longer operative, but religious leaders’ involvement in HIV prevention efforts in Pakistan continued, with these leaders involved in NACP’s stakeholder meetings and allowed space in its policy documents, press meetings and presentations.

Religious leaders

Despite the initiative’s intentions and goals, religious leaders involved in NACP did not change their understanding of or messages about HIV. These leaders rarely spoke about HIV in their communities, and when they did, they presented HIV as less of a public health problem than a moral abomination fuelled by Western cultural influences and modernisation. They continued to stigmatise, and to condemn as immoral and un-Islamic, people living with HIV and the activities that exposed them to the virus.

A booklet co-authored by these religious leaders and NACP listed these ‘immoral’ activities as ‘sexual perversion’, including same-sex relations, and ‘unnecessary delay in marriage’ (marriage at an early age was seen as a preferred HIV prevention strategy). Thus, exposure to scientific knowledge about HIV did not lead religious leaders to provide more factual information about HIV to their local communities.

The wider context

This increasingly conservative religious framework through which HIV was cast in public health messages and in NACP’s internal culture was not only due to religious leaders’ views. These biases were, to an extent, built into Pakistan’s culture and socio-political landscape. For example, Pakistani law criminalises the non-therapeutic use of drugs, sex outside marriage, homosexuality, and prostitution. The threat of prosecution for ‘conspiracy to facilitate illegal sex’ makes it difficult for HIV prevention organisations to, for example, distribute condoms to transgender people, men who have sex with men, and unmarried men and women.

Moreover, these biases were further fuelled by the introduction, in the 2000s by international organisations, of the concept of ‘risk groups’. Rather than moderate the wide-spread view of HIV as a danger to the ‘general population’ by ‘un-Islamic’ activities (e.g. same-sex encounters, premarital or extramarital sex), the concept of ‘risk groups’ increased Pakistan society’s focus on already stigmatised, criminalised, and mistreated populations of injecting drug users, transgender people, men who have sex with men, and sex workers. The formal labelling of these populations as ‘risk groups’ made their lives even more difficult, with, for example, all transgender people being cast as sex workers.

NACP staff members

Qureshi observed that NACP staff often echoed the contempt with which these groups were held in Pakistani society, describing them, in private conversations and even sometimes in official meetings, as ‘illiterate’, ‘backward’, morally suspect, and ‘sinners’. HIV activists, who the donor community considered role models for other people living with HIV, were often described in the same way. For example, one NACP staff member told Qureshi that the idea of empowering men who have sex with men was “disgusting” because they were “sinners”. Another told a gay male activist, at an official stakeholder meeting, that sex between men was “against the law of Qur’an!” They asked: “How can we support you in something that is against Allah Subhanatalla?”

Thus, while HIV officials and health experts in Pakistan formally agreed with such key aspects of international development as human rights and sexual freedom, in practice, they supported the dominant Islamic public morality. NACP staff expressed different views about groups at highest risk of HIV and HIV policy, depending on who they were speaking to at the time. For example, NACP staff emphasised their own religious piety when interacting with religious leaders, and their liberal views regarding sexual rights when interacting with development experts. When applying for funding from international sources, these same experts, consultants and officials who had denigrated people at risk of HIV used phrases designed to signify appropriate respect for and inclusion of them. For example, they took care to use such terms as ‘sexual minorities’, ‘target groups’, ‘participation’ and ‘consultation’.

Religious leaders also presented a more moderate version of their views when interacting with NACP staff, sometimes even expressing their agreement with such principles as human rights and gender equality. However, they did not take these views back to their mosques or their congregations.

National context

Qureshi cautions against assuming that all involvement of religious leaders in local HIV prevention efforts will backfire in the ways it did in Pakistan. New Islamic approaches to HIV in the African context, for example, offer alternatives to conservative religious values that are more sensitive to the realities and lived experience of HIV. However, these new Islamic theologies are not seen in most Islamic societies, including Pakistan, where HIV continues to be seen as less of a public health challenge than as a moral threat introduced by western modernity. The implications of involving religious leaders for HIV prevention – and for how people living with HIV are treated – varies by national context.