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Faith-based Responses to HIV and AIDS relating to Women in Malawi 1
Elena Sarra
	
  
Faith-based Responses to HIV & AIDS relating to Women in Malawi
Introduction
According to UNAIDS, in 2012 more than 35 million people worldwide were living with HIV, of
which 25 million, in Sub-Saharan Africa (SSA). Since its emergence as a pandemic, HIV has
attracted national and international responses leading to varied interventions globally (UNAIDS,
2013).
Malawi has been considerably successful in fighting the epidemic, with HIV prevalence declining
from almost 17% in 1999 to 10.6% in 2010 (Malawi Government, 2013). Despite this decline,
vulnerable groups remain disproportionately affected. In developing countries women are
particularly vulnerable to HIV due to their low socio-economic status, and in Malawi they
represent 58% of all people living with HIV (PLWH). In tackling the epidemic much remains to be
done, in particular to address stigma and to install a right-based approach to prevention and
care.
In recent years, Faith Based Organisations (FBOs) have been increasingly recognised as having
an integral role in the fight against HIV and AIDS. In many developing countries, including
Malawi, the overwhelming majority of the population belong to a faith group, and FBOs deliver
40% or more of healthcare services. Consequently, religious leaders and FBOs are extremely
influential in African communities and are uniquely placed to address issues relating to HIV. Their
depth of reach, particularly in rural areas, and ability to mobilise communities, make FBOs an
integral partner in delivering services to mitigate the effects of the epidemic.
Considering the leadership of the UNAIDS in this area, this essay aims to explore and critique
faith-based approaches in relation to women in Malawi, focusing on the assessment of the
effectiveness of these in addressing stigma and gender inequality, promoting a rights-based
approach to HIV prevention and care. The first part of this essay will provide context by exploring
the HIV epidemic in Malawi, examining the vulnerability of women and framing the role of FBOs
in the national fight against HIV and AIDS. The second part will proceed to examine the
Faith-based Responses to HIV and AIDS relating to Women in Malawi 2
Elena Sarra
	
  
effectiveness of faith-based approaches in relation to women in three different target areas, as
identified by the UNAIDS 2011-2015 Strategy “Getting to Zero”: Zero New Infections, Zero AIDS
related Deaths and Zero Discrimination.
Part I: Exploring the Context
Malawi Epidemiology
Malawi’s first case of AIDS was reported in Kamuzu Central Hospital in Lilongwe in 1985, with a
further 17 cases reported by the end of that year. In following years the prevalence amongst
persons aged 15-49 rose significantly, reaching a peak of 16.9% in 1999. Since then, Malawi has
been successful in reducing new infections and increasing access to treatment. According to the
2012 National Progress Report, the period between 2004 and 2010 saw the national prevalence
decline from 12% to 10.6% (Malawi Government, 2012).
However, overall prevalence is often not illustrative of inequalities within a population. For
instance, in 2010, in persons aged 15-49, prevalence was higher amongst women, at 12.9%, than
amongst men, at 8.1% (Malawi Government, 2012). Other groups such as men who have sex with
men (MSM) and female sex workers are disproportionately affected, with prevalence levels at
21.4% and 70.7% respectively. Geographically, the prevalence of urban areas is twice that of
rural areas; similarly, prevalence in the Southern region of the country is double that of the
Central and Northern regions (ibid). Such nuances and inequalities are important in order to
develop a deeper understanding of the drivers of the epidemic and to assist the mitigation of the
vulnerability of highly affected groups.
In 2011, over 75% of Malawi's HIV/AIDS interventions was funded by international donors
including the World Bank, the Global Fund, the World Health Organization, the U.S. President's
Emergency Plan for AIDS Relief (PEPFAR), and the Joint United Nations Programme on HIV and
AIDS (UNAIDS). In 2011, 65.9% of Malawi’s HIV & AIDS budget was allocated to treatment and
care, and only 11% to prevention strategies (Malawi Government, 2012).
 
Faith-based Responses to HIV and AIDS relating to Women in Malawi 3
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Government Action
In 1989, recognising the severity of the HIV/AIDS epidemic, the Government of Malawi created
the National AIDS Control Programme (NACP) and National AIDS Secretariat (NAS) to provide
technical leadership in HIV and AIDS. In 2003, the Malawi Government developed a National HIV
and AIDS Policy to provide guidelines for the design, and implementation of HIV and AIDS
interventions. More recently, the National AIDS Commission (NAC) developed the National HIV
& AIDS Strategy (2011-2016) to guide the national response to the epidemic (NAC, 2003; Malawi
Government, 2012).
Under the leadership of UNAIDS the international community has devised a wide range of
responses. The 2011 United Nations Political Declaration on AIDS aimed to set the post-2015
agenda by setting a vision to achieve Zero new HIV infections, Zero discrimination and Zero
AIDS-related deaths. Malawi’s National HIV Strategy is closely aligned with that of UNAIDS and is
currently focused on these three target areas (Malawi Government, 2013).
Women & HIV
Globally, women are disproportionately affected by HIV and AIDS, representing 52% of all
people living with HIV; however, according to UNAIDS, in Malawi this percentage increases to
58% (UNAIDS, 2014). The Government of Malawi has repeatedly recognised that the low socio-
economic status of women and gender inequalities constitute one of the major drivers of the
epidemic in the country (Malawi Government, 2013; Lindgren et al., 2005).
In addition to being physiologically more vulnerable to HIV infection than their male
counterparts, Malawian women generally have poor bargaining power in sexual relationships.
Patriarchal systems render women more susceptible to non-consensual intercourse and sexual
exploitation, which severely affects their ability to negotiate abstinence, condom use or
monogamy (UNFPA, 2013). Cultural practices such as widow inheritance (‘Choloko’), sexual
initiations and gender-based violence (GBV) create a context where women often lack ownership
and control over their sexual behaviours and practices, becoming vulnerable not only to HIV, but
Faith-based Responses to HIV and AIDS relating to Women in Malawi 4
Elena Sarra
	
  
also other sexually transmitted diseases or even unwanted pregnancies. Considering that 88% of
all new infections in Malawi are contracted through heterosexual sex, it becomes obvious why
women’s poor bargaining power in intimate relationships increases their vulnerability (Malawi
Government, 2012). According to UNAIDS, women are 55% more likely to be HIV positive if they
have experienced intimate partner violence asserting that ‘Much greater investment should be
made to address the intersections between HIV vulnerability, gender inequality and violence
against women and girls.’ (UNAIDS, 2010; 2014).
As a result of their lower status, women have limited access to education, employment, and
productive resources. In addition, traditional gender roles tend to relegate women to domestic
chores and subsidence farming, making men the primary breadwinners. Being dependent on
their husbands for financial support decreases women’s autonomy and bargaining power within
the marriage. Furthermore, when men are unable to provide for their families, women are likely
to resort to transactional sex under circumstances that make negotiation of condom use very
unlikely (UNAIDS, 2014).
Research conducted on the Malawi food crisis of 2002 revealed that during the crisis women
became increasingly engaged in unsafe transactional sex in order to support themselves and
their families (Fahy Bryceson and Fonseca, 2006). Traditionally, women are also expected to fulfil
care-giving duties not only for infants and children, but also for any elderly or sick relatives.
Consequently, women are extremely time poor, which affects their ability to pursue other income
generating activities in pursuit of financial autonomy.
Inequality continues to affect women once they are infected with HIV. Women are likely to be the
first ones to be tested and diagnosed within a family; this often means they are blamed for
infecting their spouse. Power imbalances often translate in women having to seek their husband’s
permission to access HIV treatment. Stigma and discrimination are perhaps the greatest factors
affecting women living with HIV. Exclusion from communal activities often results in decreased
income generating opportunities and marginalisation from support networks. It is possible to find
countless testimonies of communities and even relatives marginalising individuals upon
 
Faith-based Responses to HIV and AIDS relating to Women in Malawi 5
Elena Sarra
	
  
disclosure (UNAIDS, 2014). Furthermore, stigma often acts as a barrier to access of services such
as testing and treatment, thus exposing sexual partner(s) as well as future children to the virus.
Considering the focal role of women in families and communities, the welfare of women has
heavy repercussions on other groups within society. Due to motherhood and care-giving duties
being such important part of women’s role in Malawi, children and relatives can be deeply
affected if a woman is ill or passes away.
Role of FBOs
Religion and spirituality play a substantial role in the life of Malawians, with 80% of the
population identifying as Christians and 13% as Muslim. In addition to their spiritual capacity,
religious bodies are significantly involved in the delivery of care and public services. According to
the Christian Health Association Malawi (CHAM), approximately 40% of all healthcare provision in
Malawi is delivered by Christian institutions, with this percentage rising to 80% in hard-to-reach
rural areas. Studies have found that faith-based health providers deliver better services than
government facilities (Samuels, Geibel and Perry, 2010).
As a result, faith-based organisations (FBOs) are considered an integral partner in the delivery of
HIV services, and their role is widely acknowledged within the National HIV and AIDS Strategic
Plan and other national and international policies relating to HIV and AIDS (NAC, 2009). For
instance, many FBOs provide facilities for the care of PLWH, orphans and vulnerable children
(OVC) and their guardians, schools, etc.(Samuels, Geibel and Perry, 2010).
Overall, religious leaders and FBOs are extremely influential and well respected in Malawi.
Capitalising on the respect they command within society, they can deeply influence the values,
behaviours and practices of entire communities. Through their networks and structures FBOs are
able to reach even the most remote communities and are more resilient to insecurity given their
ability to mobilise local volunteers and rapid access to emergency funding (Green, 2003).
FBOs however, are often criticised for reinforcing gender inequality through gender-biased
hierarchies within their structures and for being reticent about traditional gender roles and
Faith-based Responses to HIV and AIDS relating to Women in Malawi 6
Elena Sarra
	
  
harmful traditional practices. FBO can sometimes take an active role in fuelling stigmatisation of
PLWH through the condemnation of ‘sinful behaviours’ associated with HIV transmission. Some
testimonies report religious leaders condemning condom use and family planning tools, whilst
promoting unhelpful beliefs such as prayer being a viable substitute for ART or even a cure for
HIV. Similarly, FBOs can exercise influence with the government, particularly with regards to
policy debates on legal, moral and ethical issues, as well as punitive laws (Green, 2003).
In 2000, religious leaders from Christian and Islamic religious institutions came together to
establish the Malawi Interfaith Aids Association (MIAA) whose purpose is to provide an
institutional framework for implementing strategies in the fight against HIV and AIDS within a
faith based context (MIAA, 2006). This somewhat demonstrates efforts toward a collaborative
approach, putting aside theological differences.
 
Faith-based Responses to HIV and AIDS relating to Women in Malawi 7
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Part II: Getting to Zero
Zero New Infections: Prevention
In Malawi, heterosexual sex is the predominant method of HIV transmission, accounting for 88%
of all new infections. Vertical transmission from mother to child represents a further 10% of new
infections. The fact that women are involved in 98% of all new infections makes addressing
gender inequality indisputably essential to eradicating HIV in Malawi (Malawi Government, 2012).
In promoting prevention, faith-based responses often focus on promoting the ABC approach
(Abstinence, Being faithful and Condom use). In particularly conservative circles there has been a
tendency to promote abstinence and faithfulness primarily, with condom use being met with
mixed results (Trinitapoli, 2009). Whilst the ABC approach can be useful in delaying sexual debut
and limiting chances of infection, its success is heavily dependent on men adhering to it, as
gender inequality and GBV limit women’s bargaining power in negotiating each of the three
options of ABC.
Malawi’s National Report on HIV and AIDS indicates that women become infected in at a
younger age than men, making it extremely likely that older men are seeking younger girls and
women for intercourse (Malawi Government, 2012). Difference in age and experience further
skews the power balance in favour of men, leaving the ABC approach largely dependent on their
willingness to comply.
Research shows that theological factors can fuel unhelpful attitudes around sexual behaviours
and childbearing, with FBOs often reluctant to promote family planning and condom use.
Condoms are often perceived appropriate for non-marital relations, but inappropriate within
marriage, which is supposed to involve trust and be aimed at producing children. Despite the
Catholic Church’s relaxation on the ban of condom use in 2010 with regards to discordant
couples, the ABC approach does little to contest the societal expectations around production of
offspring, which would put the negative partner at risk of infection. Should a woman refuse to
have children in the attempt to avoid infection, she would then be vulnerable to abandonment or
Faith-based Responses to HIV and AIDS relating to Women in Malawi 8
Elena Sarra
	
  
divorce, which would further increase the vulnerability of her livelihood. (Trinitapoli, 2009)
Research indicates that some FBOs have promoted counter-productive beliefs such as prayer
being a substitute for condom use, illustrating a need for reinforcing HIV and AIDS training in
theological colleges and for established religious leaders, particularly in hard to reach areas
where they are often seen as the main source of information (Malawi Government, 2012;
Trinitapoli, 2009).
Although FBOs in Malawi have been instrumental in challenging traditional marriage practices
such as polygamy and in promoting faithfulness, it is estimated that over 80% of new infections
occur within stable relationships (Malawi Government, 2009). Some interventions focus on couple
counseling thus promoting communication and respect within relationships, however it remains
doubtful that these challenge traditional gender roles that lead to inequality and vulnerability of
women.
Whilst promoting communication and respect within relationships, FBOs largely fail to advocate
women sexual and reproductive rights, particularly in regards to family planning. One could
argue that, whilst FBOs approaches to prevention aim to address risky behaviours and practices,
they fail to address the structural inequalities that drive the epidemic.
Zero Related Deaths: Treatment and Care
Although women are often the first to be diagnosed within a household, they face substantial
challenges in accessing treatment. Patriarchal hierarchies undermine their agency over own
health, as they often require permission from their husbands to access treatment. There are also
reports of women being denied access to health services as a result of stigma. In this respect, the
work of FBOs can be particularly useful. FBOs are often involved in delivering care to AIDS
patients, often mobilising communities at grass-root level to generate volunteers (Green, 2003).
This counteracts marginalisation and promotes acceptance and compassion toward the sick,
which may in turn have a positive effect on women’s access to treatment. Moreover, faith-based
approaches can deliver the moral and spiritual support that is often overlooked in other
 
Faith-based Responses to HIV and AIDS relating to Women in Malawi 9
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approaches (Ibid).
In recent years, international actors have formalised ‘The Global Plan’ towards the elimination of
new infections among children by 2015 and keeping their mothers alive. This has been a crucial
advancement for increasing women’s access to treatment, and as a result the Ministry of Health
in Malawi has implemented an innovative approach for the treatment of HIV-infected pregnant
women, named Option B+, which consists of providing life-long antiretroviral treatment to all
mothers, regardless of CD4 count (WHO, 2012). Although Option B+ suggests a deep
understanding of women’s role in society, wording around Option B+ is often focused on its
function in PMTCT and thus proposes treating women as a means to an end, rather than as an
end in itself.
Despite this, FBOs play a significant part in the delivery of this service, as they are heavily
involved in the delivery of healthcare services, particularly in hard-to-reach areas. However, as
illustrated in a study from Zambia, the availability of the service does not automatically lead to
uptake (Musheke, Bond and Merten, 2013). In the study, individuals associated illness with
feeling unwell and therefore did not seek treatment if asymptomatic. Furthermore, some studies
have shown that religious leaders at community level have been known to promote prayer and
spiritual healing as a viable alternative to ART drugs. This illustrated the need for FBOs to speak
with a united voice, ensuring that not only healthcare providers, but also religious leaders in
communities are educated about prevention, treatment and right-based access.
Nutrition is an important part of treating HIV, as treatment has been proven to be less effective in
absence of an adequately nutritious diet. Gender inequalities within families often result in men
having priority over women in access to food (Fahy Bryceson and Fonseca, 2009). FBOs have
been involved in delivering nutritional support to HIV patients, however their ability to address
priority over food remains uncertain. It can be speculated that gender inequality issues could be
addressed in counseling, support groups and pastoral care initiatives which are often delivered
by FBOs.
Not long after diagnosis, PLWH are often considered and treated as a burden on families and
Faith-based Responses to HIV and AIDS relating to Women in Malawi 10
Elena Sarra
	
  
communities. Research has revealed PLWH in some instances are described as ‘walking corpses’
and are often ‘written off’ by both religious leaders and communities, which leads to further
exclusion and increased livelihood vulnerability (UNAIDS, 2014). Consequently, promoting self-
sufficiency and dignity of PLWH is essential to the eradication of stigma and the perception that
HIV is a death sentence. Whilst there is evidence of FBOs engaging in income generating
activities for PLWH, support offered normally revolves around palliative care, nutrition, home
based care and counseling, which may be less effective in promoting dignity and self-worth,
eradicating existing perceptions (St. Peters’ Church, 2012).
Zero Discrimination
Stigma has been identified by the UNAIDS and the international community as one of the
leading drivers of the HIV epidemic. Malawi’s National HIV and AIDS policy document, produced
in 2003, denotes that discrimination against PLWH constitutes a violation of their rights and
decreases likelihood of voluntarily disclose, thus increasing their vulnerability to the virus and
chances of infecting others (NAC, 2009; MIAA, 2006).
Given their high status and influence in society, religious leaders can play an important role in the
eradication or perpetuation of stigma of PLWH; with research showing that religious leaders can
be susceptible to the temptation of exercising power over others. A study conducted in 2006
shows that, in certain areas of Malawi, up to 40% of religious leaders believed HIV to be a
deserved punishment from God/Allah for promiscuous or sinful behaviour. Despite this, interfaith
umbrella bodies such as MIAA have since worked against this trend and currently place the
eradication of stigma at the top of their HIV and AIDS agenda, recognising that “For people
living with HIV, or those assumed to be HIV-positive, no area of life is untouched by stigma and
no area of life is invulnerable to discrimination.” (MIAA, 2006).
Women are especially vulnerable to stigma, as they are most likely to be the first to be tested
within a family, consequently they are often blamed for bringing HIV into the home. Women are
also more likely to be stigmatised and excluded as their roles in society are related to chores and
 
Faith-based Responses to HIV and AIDS relating to Women in Malawi 11
Elena Sarra
	
  
tasks that can be perceived as risky of contamination, such as cooking and caregiving. In Malawi,
whilst it is widely accepted that even married men will be sexually active with multiple partners,
women are denied similar freedoms (Lindgren et al, 2005). Consequently, as HIV is perceived to
be strongly linked to polygamous behaviour, women’s HIV status disclosure often bears deeper
implication than for men.
FBOs have the capacity to mobilise volunteers and are well positioned to develop insight of the
needs of their members. As explored in the previous section, this has seen FBOs becoming
involved in the delivery of home based care initiatives through the mobilisation of members
within the community (Green, 2003). Besides delivering practical support, such an approach can
help break barriers and eradicate stigma by sensitising members of the community to the needs
and challenges faced by PLWH FBOs are also uniquely placed to promote acceptance, care and
tolerance of PLWH.
In recent years, since the formalisation of the GIPA Principle, there has been increasing
recognition amongst FBOs of the importance of adopting a Human-Rights-focused approach and
pursue the inclusion and involvement of PLWH. The GIPA Principle was stipulated at the 1994
Paris AIDS Summit, where 42 nations agreed to “support a greater involvement of people living
with HIV/AIDS at all levels and to stimulate the creation of supportive political, legal and social
environments” (UNAIDS, 2007).
More recently, in August 2013, the inclusion of religious leaders in capacity-building around HIV
and Human Rights has been reinforced by the creation of the ‘Framework for Dialogue’, a tool for
increasing efficient, inclusive and continued dialogue and collaboration between PLWH and
religious leaders to address stigma and discrimination (Ibid). This development is certainly
promising and indicative of progress toward a multi-dimensional, human rights approach to
addressing stigma where those affected have a voice and can exercise agency.
Stigma can often be legitimised by punitive laws such as criminalisation of HIV transmission and
anti-gay legislation, particularly in and African context. Adoption of legislation favouring the
Criminalisation of HIV transmission has been considered in several countries including Malawi,
Faith-based Responses to HIV and AIDS relating to Women in Malawi 12
Elena Sarra
	
  
however it was ultimately refused. Such legislation would be detrimental to women as they are
often mistakenly blamed for infecting partners and are frequently unable to negotiate sexual
practices, even once infected (UNAIDS, 2012).
Another point to consider is the condemnation of homosexual behaviours and practices.
Although, perhaps unsurprisingly, homosexual practices were not listed in the list of methods of
transmission in the 2013 National Report on HIV and AIDS, prevalence amongst MSM was
double that of the national average at 21.4% (Malawi Government, 2009). Malawi currently has
punitive anti-gay legislation in place, with perpetrators facing up to 14 years of imprisonment. It
is undeniable that religion has played a vital role in the condemnation of homosexuality, thus
undermining its overarching message of tolerance and compassion normally used by FBOs to
reduce stigma. This further exacerbates the vulnerability of minority groups such as MSM and
could fuel stigma and discrimination toward all groups that are perceived to be minorities.
Furthermore, this illustrates that despite efforts to reduce stigma associated with HIV, FBOs still
have progress to make with regards to adopting a non-judgement, rights-based approach to HIV
and AIDS.
 
Faith-based Responses to HIV and AIDS relating to Women in Malawi 13
Elena Sarra
	
  
Conclusion
Preventing the spread of HIV/AIDS in Malawi is a critical public health concern. Despite success
in curbing prevalence, research has consistently shown that gender inequality and women’s lack
of autonomy in many crucial aspects of their lives is a significant barrier in controlling the
epidemic.
FBOs are uniquely placed in African societies both because of the influence and respect they
command, but also due to their ability to reach even the most remote areas and their
involvement in providing healthcare services. Religious leaders have insight and well-rounded
knowledge of their communities’ needs and at the same time have power to influence policy
making and government action.
Their influence within communities enables them to influence behaviours and attitudes,
particularly with regards to stigma and discrimination. FBOs are involved in the delivery of
grassroots projects that involve mobilisation of volunteers, with much scope for breaking barriers
and misconceptions.
Although there has been a recent progress toward human rights approaches and increasing
recognition of the need for inclusion and cooperation of PLWH, theological beliefs of FBOs still
promote unhelpful behaviours and fuel punitive laws that can be extremely detrimental for
vulnerable minority groups such as women and MSM.
The overwhelming majority of faith-based responses revolve around offering practical support
and the promotion of moral values such as compassion and acceptance at community level.
Although these can be helpful in mitigating the effects of HIV and AIDS, they do not address the
gender inequalities and social constructs that lie at the core of women’s vulnerability. Failure to
address these issues can often undermine the positive outcomes that are unique to faith-based
approaches and exacerbate vulnerability of minorities. In conclusion, FBOs’ commitment to
reducing stigma and to a rights-based approach can often be superficial. A much deeper
understanding of gender inequalities and a true commitment to addressing these is needed in
order to capitalise on the unique place and status that FBOs enjoy in African communities.
Faith-based Responses to HIV and AIDS relating to Women in Malawi 14
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Faith-based Responses to HIV and AIDS relating to Women in Malawi - Elena Sarra

  • 1.   Faith-based Responses to HIV and AIDS relating to Women in Malawi 1 Elena Sarra   Faith-based Responses to HIV & AIDS relating to Women in Malawi Introduction According to UNAIDS, in 2012 more than 35 million people worldwide were living with HIV, of which 25 million, in Sub-Saharan Africa (SSA). Since its emergence as a pandemic, HIV has attracted national and international responses leading to varied interventions globally (UNAIDS, 2013). Malawi has been considerably successful in fighting the epidemic, with HIV prevalence declining from almost 17% in 1999 to 10.6% in 2010 (Malawi Government, 2013). Despite this decline, vulnerable groups remain disproportionately affected. In developing countries women are particularly vulnerable to HIV due to their low socio-economic status, and in Malawi they represent 58% of all people living with HIV (PLWH). In tackling the epidemic much remains to be done, in particular to address stigma and to install a right-based approach to prevention and care. In recent years, Faith Based Organisations (FBOs) have been increasingly recognised as having an integral role in the fight against HIV and AIDS. In many developing countries, including Malawi, the overwhelming majority of the population belong to a faith group, and FBOs deliver 40% or more of healthcare services. Consequently, religious leaders and FBOs are extremely influential in African communities and are uniquely placed to address issues relating to HIV. Their depth of reach, particularly in rural areas, and ability to mobilise communities, make FBOs an integral partner in delivering services to mitigate the effects of the epidemic. Considering the leadership of the UNAIDS in this area, this essay aims to explore and critique faith-based approaches in relation to women in Malawi, focusing on the assessment of the effectiveness of these in addressing stigma and gender inequality, promoting a rights-based approach to HIV prevention and care. The first part of this essay will provide context by exploring the HIV epidemic in Malawi, examining the vulnerability of women and framing the role of FBOs in the national fight against HIV and AIDS. The second part will proceed to examine the
  • 2. Faith-based Responses to HIV and AIDS relating to Women in Malawi 2 Elena Sarra   effectiveness of faith-based approaches in relation to women in three different target areas, as identified by the UNAIDS 2011-2015 Strategy “Getting to Zero”: Zero New Infections, Zero AIDS related Deaths and Zero Discrimination. Part I: Exploring the Context Malawi Epidemiology Malawi’s first case of AIDS was reported in Kamuzu Central Hospital in Lilongwe in 1985, with a further 17 cases reported by the end of that year. In following years the prevalence amongst persons aged 15-49 rose significantly, reaching a peak of 16.9% in 1999. Since then, Malawi has been successful in reducing new infections and increasing access to treatment. According to the 2012 National Progress Report, the period between 2004 and 2010 saw the national prevalence decline from 12% to 10.6% (Malawi Government, 2012). However, overall prevalence is often not illustrative of inequalities within a population. For instance, in 2010, in persons aged 15-49, prevalence was higher amongst women, at 12.9%, than amongst men, at 8.1% (Malawi Government, 2012). Other groups such as men who have sex with men (MSM) and female sex workers are disproportionately affected, with prevalence levels at 21.4% and 70.7% respectively. Geographically, the prevalence of urban areas is twice that of rural areas; similarly, prevalence in the Southern region of the country is double that of the Central and Northern regions (ibid). Such nuances and inequalities are important in order to develop a deeper understanding of the drivers of the epidemic and to assist the mitigation of the vulnerability of highly affected groups. In 2011, over 75% of Malawi's HIV/AIDS interventions was funded by international donors including the World Bank, the Global Fund, the World Health Organization, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), and the Joint United Nations Programme on HIV and AIDS (UNAIDS). In 2011, 65.9% of Malawi’s HIV & AIDS budget was allocated to treatment and care, and only 11% to prevention strategies (Malawi Government, 2012).
  • 3.   Faith-based Responses to HIV and AIDS relating to Women in Malawi 3 Elena Sarra   Government Action In 1989, recognising the severity of the HIV/AIDS epidemic, the Government of Malawi created the National AIDS Control Programme (NACP) and National AIDS Secretariat (NAS) to provide technical leadership in HIV and AIDS. In 2003, the Malawi Government developed a National HIV and AIDS Policy to provide guidelines for the design, and implementation of HIV and AIDS interventions. More recently, the National AIDS Commission (NAC) developed the National HIV & AIDS Strategy (2011-2016) to guide the national response to the epidemic (NAC, 2003; Malawi Government, 2012). Under the leadership of UNAIDS the international community has devised a wide range of responses. The 2011 United Nations Political Declaration on AIDS aimed to set the post-2015 agenda by setting a vision to achieve Zero new HIV infections, Zero discrimination and Zero AIDS-related deaths. Malawi’s National HIV Strategy is closely aligned with that of UNAIDS and is currently focused on these three target areas (Malawi Government, 2013). Women & HIV Globally, women are disproportionately affected by HIV and AIDS, representing 52% of all people living with HIV; however, according to UNAIDS, in Malawi this percentage increases to 58% (UNAIDS, 2014). The Government of Malawi has repeatedly recognised that the low socio- economic status of women and gender inequalities constitute one of the major drivers of the epidemic in the country (Malawi Government, 2013; Lindgren et al., 2005). In addition to being physiologically more vulnerable to HIV infection than their male counterparts, Malawian women generally have poor bargaining power in sexual relationships. Patriarchal systems render women more susceptible to non-consensual intercourse and sexual exploitation, which severely affects their ability to negotiate abstinence, condom use or monogamy (UNFPA, 2013). Cultural practices such as widow inheritance (‘Choloko’), sexual initiations and gender-based violence (GBV) create a context where women often lack ownership and control over their sexual behaviours and practices, becoming vulnerable not only to HIV, but
  • 4. Faith-based Responses to HIV and AIDS relating to Women in Malawi 4 Elena Sarra   also other sexually transmitted diseases or even unwanted pregnancies. Considering that 88% of all new infections in Malawi are contracted through heterosexual sex, it becomes obvious why women’s poor bargaining power in intimate relationships increases their vulnerability (Malawi Government, 2012). According to UNAIDS, women are 55% more likely to be HIV positive if they have experienced intimate partner violence asserting that ‘Much greater investment should be made to address the intersections between HIV vulnerability, gender inequality and violence against women and girls.’ (UNAIDS, 2010; 2014). As a result of their lower status, women have limited access to education, employment, and productive resources. In addition, traditional gender roles tend to relegate women to domestic chores and subsidence farming, making men the primary breadwinners. Being dependent on their husbands for financial support decreases women’s autonomy and bargaining power within the marriage. Furthermore, when men are unable to provide for their families, women are likely to resort to transactional sex under circumstances that make negotiation of condom use very unlikely (UNAIDS, 2014). Research conducted on the Malawi food crisis of 2002 revealed that during the crisis women became increasingly engaged in unsafe transactional sex in order to support themselves and their families (Fahy Bryceson and Fonseca, 2006). Traditionally, women are also expected to fulfil care-giving duties not only for infants and children, but also for any elderly or sick relatives. Consequently, women are extremely time poor, which affects their ability to pursue other income generating activities in pursuit of financial autonomy. Inequality continues to affect women once they are infected with HIV. Women are likely to be the first ones to be tested and diagnosed within a family; this often means they are blamed for infecting their spouse. Power imbalances often translate in women having to seek their husband’s permission to access HIV treatment. Stigma and discrimination are perhaps the greatest factors affecting women living with HIV. Exclusion from communal activities often results in decreased income generating opportunities and marginalisation from support networks. It is possible to find countless testimonies of communities and even relatives marginalising individuals upon
  • 5.   Faith-based Responses to HIV and AIDS relating to Women in Malawi 5 Elena Sarra   disclosure (UNAIDS, 2014). Furthermore, stigma often acts as a barrier to access of services such as testing and treatment, thus exposing sexual partner(s) as well as future children to the virus. Considering the focal role of women in families and communities, the welfare of women has heavy repercussions on other groups within society. Due to motherhood and care-giving duties being such important part of women’s role in Malawi, children and relatives can be deeply affected if a woman is ill or passes away. Role of FBOs Religion and spirituality play a substantial role in the life of Malawians, with 80% of the population identifying as Christians and 13% as Muslim. In addition to their spiritual capacity, religious bodies are significantly involved in the delivery of care and public services. According to the Christian Health Association Malawi (CHAM), approximately 40% of all healthcare provision in Malawi is delivered by Christian institutions, with this percentage rising to 80% in hard-to-reach rural areas. Studies have found that faith-based health providers deliver better services than government facilities (Samuels, Geibel and Perry, 2010). As a result, faith-based organisations (FBOs) are considered an integral partner in the delivery of HIV services, and their role is widely acknowledged within the National HIV and AIDS Strategic Plan and other national and international policies relating to HIV and AIDS (NAC, 2009). For instance, many FBOs provide facilities for the care of PLWH, orphans and vulnerable children (OVC) and their guardians, schools, etc.(Samuels, Geibel and Perry, 2010). Overall, religious leaders and FBOs are extremely influential and well respected in Malawi. Capitalising on the respect they command within society, they can deeply influence the values, behaviours and practices of entire communities. Through their networks and structures FBOs are able to reach even the most remote communities and are more resilient to insecurity given their ability to mobilise local volunteers and rapid access to emergency funding (Green, 2003). FBOs however, are often criticised for reinforcing gender inequality through gender-biased hierarchies within their structures and for being reticent about traditional gender roles and
  • 6. Faith-based Responses to HIV and AIDS relating to Women in Malawi 6 Elena Sarra   harmful traditional practices. FBO can sometimes take an active role in fuelling stigmatisation of PLWH through the condemnation of ‘sinful behaviours’ associated with HIV transmission. Some testimonies report religious leaders condemning condom use and family planning tools, whilst promoting unhelpful beliefs such as prayer being a viable substitute for ART or even a cure for HIV. Similarly, FBOs can exercise influence with the government, particularly with regards to policy debates on legal, moral and ethical issues, as well as punitive laws (Green, 2003). In 2000, religious leaders from Christian and Islamic religious institutions came together to establish the Malawi Interfaith Aids Association (MIAA) whose purpose is to provide an institutional framework for implementing strategies in the fight against HIV and AIDS within a faith based context (MIAA, 2006). This somewhat demonstrates efforts toward a collaborative approach, putting aside theological differences.
  • 7.   Faith-based Responses to HIV and AIDS relating to Women in Malawi 7 Elena Sarra   Part II: Getting to Zero Zero New Infections: Prevention In Malawi, heterosexual sex is the predominant method of HIV transmission, accounting for 88% of all new infections. Vertical transmission from mother to child represents a further 10% of new infections. The fact that women are involved in 98% of all new infections makes addressing gender inequality indisputably essential to eradicating HIV in Malawi (Malawi Government, 2012). In promoting prevention, faith-based responses often focus on promoting the ABC approach (Abstinence, Being faithful and Condom use). In particularly conservative circles there has been a tendency to promote abstinence and faithfulness primarily, with condom use being met with mixed results (Trinitapoli, 2009). Whilst the ABC approach can be useful in delaying sexual debut and limiting chances of infection, its success is heavily dependent on men adhering to it, as gender inequality and GBV limit women’s bargaining power in negotiating each of the three options of ABC. Malawi’s National Report on HIV and AIDS indicates that women become infected in at a younger age than men, making it extremely likely that older men are seeking younger girls and women for intercourse (Malawi Government, 2012). Difference in age and experience further skews the power balance in favour of men, leaving the ABC approach largely dependent on their willingness to comply. Research shows that theological factors can fuel unhelpful attitudes around sexual behaviours and childbearing, with FBOs often reluctant to promote family planning and condom use. Condoms are often perceived appropriate for non-marital relations, but inappropriate within marriage, which is supposed to involve trust and be aimed at producing children. Despite the Catholic Church’s relaxation on the ban of condom use in 2010 with regards to discordant couples, the ABC approach does little to contest the societal expectations around production of offspring, which would put the negative partner at risk of infection. Should a woman refuse to have children in the attempt to avoid infection, she would then be vulnerable to abandonment or
  • 8. Faith-based Responses to HIV and AIDS relating to Women in Malawi 8 Elena Sarra   divorce, which would further increase the vulnerability of her livelihood. (Trinitapoli, 2009) Research indicates that some FBOs have promoted counter-productive beliefs such as prayer being a substitute for condom use, illustrating a need for reinforcing HIV and AIDS training in theological colleges and for established religious leaders, particularly in hard to reach areas where they are often seen as the main source of information (Malawi Government, 2012; Trinitapoli, 2009). Although FBOs in Malawi have been instrumental in challenging traditional marriage practices such as polygamy and in promoting faithfulness, it is estimated that over 80% of new infections occur within stable relationships (Malawi Government, 2009). Some interventions focus on couple counseling thus promoting communication and respect within relationships, however it remains doubtful that these challenge traditional gender roles that lead to inequality and vulnerability of women. Whilst promoting communication and respect within relationships, FBOs largely fail to advocate women sexual and reproductive rights, particularly in regards to family planning. One could argue that, whilst FBOs approaches to prevention aim to address risky behaviours and practices, they fail to address the structural inequalities that drive the epidemic. Zero Related Deaths: Treatment and Care Although women are often the first to be diagnosed within a household, they face substantial challenges in accessing treatment. Patriarchal hierarchies undermine their agency over own health, as they often require permission from their husbands to access treatment. There are also reports of women being denied access to health services as a result of stigma. In this respect, the work of FBOs can be particularly useful. FBOs are often involved in delivering care to AIDS patients, often mobilising communities at grass-root level to generate volunteers (Green, 2003). This counteracts marginalisation and promotes acceptance and compassion toward the sick, which may in turn have a positive effect on women’s access to treatment. Moreover, faith-based approaches can deliver the moral and spiritual support that is often overlooked in other
  • 9.   Faith-based Responses to HIV and AIDS relating to Women in Malawi 9 Elena Sarra   approaches (Ibid). In recent years, international actors have formalised ‘The Global Plan’ towards the elimination of new infections among children by 2015 and keeping their mothers alive. This has been a crucial advancement for increasing women’s access to treatment, and as a result the Ministry of Health in Malawi has implemented an innovative approach for the treatment of HIV-infected pregnant women, named Option B+, which consists of providing life-long antiretroviral treatment to all mothers, regardless of CD4 count (WHO, 2012). Although Option B+ suggests a deep understanding of women’s role in society, wording around Option B+ is often focused on its function in PMTCT and thus proposes treating women as a means to an end, rather than as an end in itself. Despite this, FBOs play a significant part in the delivery of this service, as they are heavily involved in the delivery of healthcare services, particularly in hard-to-reach areas. However, as illustrated in a study from Zambia, the availability of the service does not automatically lead to uptake (Musheke, Bond and Merten, 2013). In the study, individuals associated illness with feeling unwell and therefore did not seek treatment if asymptomatic. Furthermore, some studies have shown that religious leaders at community level have been known to promote prayer and spiritual healing as a viable alternative to ART drugs. This illustrated the need for FBOs to speak with a united voice, ensuring that not only healthcare providers, but also religious leaders in communities are educated about prevention, treatment and right-based access. Nutrition is an important part of treating HIV, as treatment has been proven to be less effective in absence of an adequately nutritious diet. Gender inequalities within families often result in men having priority over women in access to food (Fahy Bryceson and Fonseca, 2009). FBOs have been involved in delivering nutritional support to HIV patients, however their ability to address priority over food remains uncertain. It can be speculated that gender inequality issues could be addressed in counseling, support groups and pastoral care initiatives which are often delivered by FBOs. Not long after diagnosis, PLWH are often considered and treated as a burden on families and
  • 10. Faith-based Responses to HIV and AIDS relating to Women in Malawi 10 Elena Sarra   communities. Research has revealed PLWH in some instances are described as ‘walking corpses’ and are often ‘written off’ by both religious leaders and communities, which leads to further exclusion and increased livelihood vulnerability (UNAIDS, 2014). Consequently, promoting self- sufficiency and dignity of PLWH is essential to the eradication of stigma and the perception that HIV is a death sentence. Whilst there is evidence of FBOs engaging in income generating activities for PLWH, support offered normally revolves around palliative care, nutrition, home based care and counseling, which may be less effective in promoting dignity and self-worth, eradicating existing perceptions (St. Peters’ Church, 2012). Zero Discrimination Stigma has been identified by the UNAIDS and the international community as one of the leading drivers of the HIV epidemic. Malawi’s National HIV and AIDS policy document, produced in 2003, denotes that discrimination against PLWH constitutes a violation of their rights and decreases likelihood of voluntarily disclose, thus increasing their vulnerability to the virus and chances of infecting others (NAC, 2009; MIAA, 2006). Given their high status and influence in society, religious leaders can play an important role in the eradication or perpetuation of stigma of PLWH; with research showing that religious leaders can be susceptible to the temptation of exercising power over others. A study conducted in 2006 shows that, in certain areas of Malawi, up to 40% of religious leaders believed HIV to be a deserved punishment from God/Allah for promiscuous or sinful behaviour. Despite this, interfaith umbrella bodies such as MIAA have since worked against this trend and currently place the eradication of stigma at the top of their HIV and AIDS agenda, recognising that “For people living with HIV, or those assumed to be HIV-positive, no area of life is untouched by stigma and no area of life is invulnerable to discrimination.” (MIAA, 2006). Women are especially vulnerable to stigma, as they are most likely to be the first to be tested within a family, consequently they are often blamed for bringing HIV into the home. Women are also more likely to be stigmatised and excluded as their roles in society are related to chores and
  • 11.   Faith-based Responses to HIV and AIDS relating to Women in Malawi 11 Elena Sarra   tasks that can be perceived as risky of contamination, such as cooking and caregiving. In Malawi, whilst it is widely accepted that even married men will be sexually active with multiple partners, women are denied similar freedoms (Lindgren et al, 2005). Consequently, as HIV is perceived to be strongly linked to polygamous behaviour, women’s HIV status disclosure often bears deeper implication than for men. FBOs have the capacity to mobilise volunteers and are well positioned to develop insight of the needs of their members. As explored in the previous section, this has seen FBOs becoming involved in the delivery of home based care initiatives through the mobilisation of members within the community (Green, 2003). Besides delivering practical support, such an approach can help break barriers and eradicate stigma by sensitising members of the community to the needs and challenges faced by PLWH FBOs are also uniquely placed to promote acceptance, care and tolerance of PLWH. In recent years, since the formalisation of the GIPA Principle, there has been increasing recognition amongst FBOs of the importance of adopting a Human-Rights-focused approach and pursue the inclusion and involvement of PLWH. The GIPA Principle was stipulated at the 1994 Paris AIDS Summit, where 42 nations agreed to “support a greater involvement of people living with HIV/AIDS at all levels and to stimulate the creation of supportive political, legal and social environments” (UNAIDS, 2007). More recently, in August 2013, the inclusion of religious leaders in capacity-building around HIV and Human Rights has been reinforced by the creation of the ‘Framework for Dialogue’, a tool for increasing efficient, inclusive and continued dialogue and collaboration between PLWH and religious leaders to address stigma and discrimination (Ibid). This development is certainly promising and indicative of progress toward a multi-dimensional, human rights approach to addressing stigma where those affected have a voice and can exercise agency. Stigma can often be legitimised by punitive laws such as criminalisation of HIV transmission and anti-gay legislation, particularly in and African context. Adoption of legislation favouring the Criminalisation of HIV transmission has been considered in several countries including Malawi,
  • 12. Faith-based Responses to HIV and AIDS relating to Women in Malawi 12 Elena Sarra   however it was ultimately refused. Such legislation would be detrimental to women as they are often mistakenly blamed for infecting partners and are frequently unable to negotiate sexual practices, even once infected (UNAIDS, 2012). Another point to consider is the condemnation of homosexual behaviours and practices. Although, perhaps unsurprisingly, homosexual practices were not listed in the list of methods of transmission in the 2013 National Report on HIV and AIDS, prevalence amongst MSM was double that of the national average at 21.4% (Malawi Government, 2009). Malawi currently has punitive anti-gay legislation in place, with perpetrators facing up to 14 years of imprisonment. It is undeniable that religion has played a vital role in the condemnation of homosexuality, thus undermining its overarching message of tolerance and compassion normally used by FBOs to reduce stigma. This further exacerbates the vulnerability of minority groups such as MSM and could fuel stigma and discrimination toward all groups that are perceived to be minorities. Furthermore, this illustrates that despite efforts to reduce stigma associated with HIV, FBOs still have progress to make with regards to adopting a non-judgement, rights-based approach to HIV and AIDS.
  • 13.   Faith-based Responses to HIV and AIDS relating to Women in Malawi 13 Elena Sarra   Conclusion Preventing the spread of HIV/AIDS in Malawi is a critical public health concern. Despite success in curbing prevalence, research has consistently shown that gender inequality and women’s lack of autonomy in many crucial aspects of their lives is a significant barrier in controlling the epidemic. FBOs are uniquely placed in African societies both because of the influence and respect they command, but also due to their ability to reach even the most remote areas and their involvement in providing healthcare services. Religious leaders have insight and well-rounded knowledge of their communities’ needs and at the same time have power to influence policy making and government action. Their influence within communities enables them to influence behaviours and attitudes, particularly with regards to stigma and discrimination. FBOs are involved in the delivery of grassroots projects that involve mobilisation of volunteers, with much scope for breaking barriers and misconceptions. Although there has been a recent progress toward human rights approaches and increasing recognition of the need for inclusion and cooperation of PLWH, theological beliefs of FBOs still promote unhelpful behaviours and fuel punitive laws that can be extremely detrimental for vulnerable minority groups such as women and MSM. The overwhelming majority of faith-based responses revolve around offering practical support and the promotion of moral values such as compassion and acceptance at community level. Although these can be helpful in mitigating the effects of HIV and AIDS, they do not address the gender inequalities and social constructs that lie at the core of women’s vulnerability. Failure to address these issues can often undermine the positive outcomes that are unique to faith-based approaches and exacerbate vulnerability of minorities. In conclusion, FBOs’ commitment to reducing stigma and to a rights-based approach can often be superficial. A much deeper understanding of gender inequalities and a true commitment to addressing these is needed in order to capitalise on the unique place and status that FBOs enjoy in African communities.
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