HIV in Senegal: Religion and Responsibility
David Ansari is currently on a Fullbright scholarship in Senegal and here he takes an indepth look at the influence of religion on HIV/AIDS
In a country where less than 2% (1)(2)(3)(4) of the general population is living with HIV, a statistic that has heralded Senegal as a model country in terms of avoiding the AIDS epidemic, how are people living with HIV/AIDS (PLWHA) perceived? What is the root of these perceptions, and how can the situation for patients be improved if such perceptions are harmful? Studies conducted in South Africa and Haiti found that stigma and discrimination have been purported to be less pervasive in areas where antiretroviral medications are more available (5)(6)(7), as is the case in Senegal. Yet a study done in Mali found that stigma experienced by PLWHA may be higher in low prevalence settings and people may be at a higher risk of discrimination if they choose to disclose their serostatus (8). Perhaps the association of HIV as a deadly illness is not so much the root of HIV-related stigma as is the equation with sexual promiscuity, sin and immorality (5)(9).
I asked a colleague, a member of network of PLWHA in Senegal and speaker at HIV awareness workshops, what he thinks is responsible for stigma. He told me that people never seem to be satisfied when he tells his personal story of infection from a blood transfusion; many expect him to recount tales of stereotypical sexual hedonism. My colleague is certainly not in the minority, as other studies have found that PLWHA are often blamed for their infection, since responsibility is attributed to lifestyle and moral decision-making (10)(11). The stigma experienced is generally the most severe in cases where the individual is perceived as responsible for becoming ill (12). In this context, is it easier for people to react towards a seropositive individual if she/he is perceived as responsible for his illness? A Chinese study conducted in a rural community in which the majority of PLWHA were infected as a result of plasma donations found that stigmatizing attitudes persisted (13) even though the individual infected was considered blameless. Clearly, not every infection is a result of sexual transmission, let alone a form of sexual transmission deemed as socially unacceptable; but when someone is known to be serpositive yet the cause of infection is not disclosed, how is the individual’s treatment by her/his milieu affected? Is social reaction to infection governed by its mode of transmission? If so, this can have dangerous implications for those affected by HIV.
Around 90% of the population is Muslim, so how does religion play a role in combating or fueling these perceptions? Religion itself has often been cited as one of the pillars of HIV prevention in Senegal, with low reported extramarital sex perceived as partly responsible (1). A study assessing the needs of HIV-positive patients in Senegal found that principal concerns among patients included the maintenance of family harmony and access to spiritual support (14). A study conducted in the United States found that spiritual well-being promotes healthy social and personal behavior, including coping, and may help combat psychological problems (15). Religious recommendations usually stress the importance of abstinence and fidelity before the use of condoms, which is consistent with existing cultural beliefs of sexuality and prevention of sexually transmitted infection (16). What purpose do these recommendations serve if someone is already infected? Someone who is already living with HIV may be worse off if she/he is seen as living in violation of these recommendations, even if HIV was not contracted through extramarital sex.
I made my research priority to talk to religieux: imams, priests, religious community leaders and traditional healers to gain a better understanding of the role of religion in the care and support of PLWHA. Religious leaders play an important role in HIV/AIDS-related communication as they are heirs of religious science and wisdom (17). One imam from a neighborhood on the outskirts of Dakar told me that Islamic leaders have the chance to reach their followers five times per day and that many followers come to the mosque, so it’s quite easy to talk about HIV. Religious leaders such as imams have access to a large number of people of different age groups, which makes them essential in the dissemination of education.
Preliminary data from 17 interviews with informants from each of the groups mentioned above in or around Dakar, the capital city of Senegal, were used for this analysis. A focus group also took place with a group of five imams, one of whom was included in a one-on-one interview. Each participant gave consent before the interview began and all but two were recorded. All participants were men, as are most religious leaders in Senegal. All participants identified as being Muslim aside from a Catholic priest. Interviews took place usually in the home or the office of the participant, in French or Wolof (the latter with the assistance of a translator), and lasted anywhere from 30 minutes to a few hours.
All but five had attended some form of informational activity about HIV/AIDS. Eight responded that they taught or gave advice on the care and support of PLWHA. Twelve responded that they taught some form of sexual education and prevention. One imam did not answer many of my questions but stated that the best form of prevention was to not approach PLWHA. He said “they should be separated and treated, but not left in society; if they are left with their families, the entire family will be infected.” His opinion is in the minority in my group of participants, who generally said that PLWHA should be treated as any other sick person. Our interview took place in front of three of his students, all of whom nodded readily in agreement with his recommendations. I mention this example to demonstrate the power of communication from one leader to the wider community.
I asked an imam from Yoff, located on the north side of Dakar, how he would respond to someone who claims that religious messages encourage some of the false perceptions of HIV/AIDS. He told me that HIV/AIDS cannot exist among Muslims if they abstain and do not commit adultery; if they follow the teachings of the Koran, they will not have AIDS. Another told me that Islam had already found a remedy for AIDS, which is to abide by the teachings of the Koran. But what about those who do follow the teachings of the Koran (or any other religious text for that matter), who abstain until marriage and remain faithful while married, but then become infected because their partner did not live up to the same religious recommendations? If they get thrown into the same category as those who become infected as a result of “sexual vagabondage,” then they will experience stigma because they are perceived as personally responsible.
I asked each of my participants whether they thought that those affected by HIV were responsible for their illness. Ten participants said that some PLWHA are responsible and some aren’t. Seven gave me examples of those who are victims, such as children born with the virus or those who get it from unsterilized instruments used in a hospital setting or at the barber shop. They then proceeded to give examples of those who are responsible, such as those who don’t abstain, those who engage in homosexual intercourse, and those who don’t use contraception. A youth leader told me that we cannot possibly think of someone as responsible because there are so many ways that HIV can be transmitted. An imam told me that nobody with HIV/AIDS is responsible because God made the illness just like everything else on earth. An imam from a suburb of Dakar told me that 90% of PLWHA are responsible. This is a particularly startling response because it represents a perception of an important research finding. Most cases of HIV transmission in Senegal occur through heterosexual intercourse (18), but can we say that all are responsible if they became infected in this manner? A Catholic priest told me that we should not make any judgments unless we know each person’s history. But even if we know everyone’s stories, should we make judgments?
Manifestations of stigma aren’t always obvious and when members of a stigmatized group, such as PLWHA, do not experience discrimination directly, they may remain associated with “stigmatised markers,” or negative perceptions that may become internalized, with consequences affecting confidence and self-esteem (19)(5)(12). When someone is struggling to reconcile an illness such as HIV, confidence and self-esteem are essential. I asked all of the participants who they believed are responsible for creating an environment for PLWHA without stigma and discrimination. Four participants said that everyone needed to take part; three said that it was the responsibility of the state, seven stated religious leaders, and three didn’t know or chose not to respond. I also asked everyone how they would counsel someone experiencing isolation as a result of seropositivity. One stated that we need to give material and moral support if we have the means. Another said he would recommend the individual to remain integrated in society but to be conscious of his illness. Three said that living with HIV/AIDS is just like living with any other illness, and people with these other illnesses are still living in society. Two said that they would directly help and make themselves available, three gave recommendations of whom to consult, such as associations of PLWHA or people with more HIV-related knowledge, such as physicians. All but one believed that it was necessary for the individual to remain a part of society; in fact, there is an expression in Wolof “bul daw ku were di,” meaning that to flee someone who is ill will only augment his illness.
The nuances surrounding stigma related to HIV are extremely complex, particularly in the Senegalese society. A youth leader told me that in Senegal, solidarity is part of everyday life. Almost all of the participants engage in some form of HIV education activity, and this sort of participation is necessary to demonstrate concern and ultimately improve the climate for PLWHA. Responsibility surrounding HIV infection is particularly delicate. People need to know that they have the responsibility to prevent infection by practicing prevention and harm reduction. Still, responsibility needs to be approached in a manner so that it is not equated with guilt so that those who are living with HIV or AIDS are not perceived as having violated social and religious guidelines. In the cases whence such perceptions of responsibility prove harmful for PLWHA, then it is up to the religieux to guide their followers away from associations between responsibility and blame. During my focus group with five imams, we discussed HIV as a divine punishment. It was said that infection is a punishment if a man sleeps with a woman who is not his wife, but in any case, God will pardon all. Pardoning is appealing as it allows us to look forward to making the best possible situation for PLWHA by blurring the notion of responsibility. Religious leaders need to communicate that after one becomes infected with HIV, the only relevant responsibility is that of the community to unconditionally take care of those who are ill.
David Ansari
Fullbright scholar
Senegal
ansari.david@gmail.com
David Ansari is with Fulbright and is in Senegal investigating the role of the religious community in the reduction of HIV/AIDS-related stigma and discrimination. He is with the University of Minnesota in Minneapolis, MN USA.
(1) Sayagues, M. (2006). A Genuine Concern for Public Health: The Government of Senegal’s Response to the Threat of AIDS. Africa’s Tsunami: Turning the Tide on AIDS. The South African Institute of International Affairs.
(2) Senegal: Epidemiological Fact Sheets On HIV/AIDS and Sexually Transmitted Infections. World Health Organization 2006. http://www.who.int/countries/sen/en/
(3) Sénégal: Annuaire Statistique 2004. Ministère de la Santé et la Prévention Médicale. http://www.sante.gouv.sn/
(4) AIDS Epidemic Update December 2007. Joint United Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO).
(5) Campbell, C., Foulis, C.A., Maimane, S., and Sibiya, Z. (2005). “I have an evil child at my house”: Stigma and HIV/AIDS management in a South African community. American Journal of Public Health, 95: 808-815.
(6) Castro, A. and Farmer, P. (2005). Understanding and Addressing AIDS-Related Stigma: From Anthropological Theory to Clinical Practice in Haiti. American Journal of Public Health, 95: 53-59
(7) Krakauer, M. and Newbery, J. (2007). Churches’ Responses to HIV/AIDS in two South African Communities. Journal of the International Association of Physicians AIDS Care, 6: 27-35.
(8) Castle, S. (2004). Rural children’s attitudes to people with HIV/AIDS in Mali: the causes of stigma. Culture, Health, and Sexuality 6: 1-18
(9) Campbell, C., Nair, Y., and Maimane, S. (2006). AIDS stigma, sexual moralities and the policing of women and youth in South Africa. Feminist Review, 83: 132-138.
(10) Brimlow, D.L., Cook, J.S., and Seaton, R. (2003). Stigma and HIV/AIDS: A review of the literature. U.S. Department of Health and Human Services Health Resources and Services Administration. http://hab.hrsa.gov/publications/stigma/stigma_and_the_general_population.htm
(11) Tarabay, M. (2000). Les stigmates de la maladie: Représentations socials de l’épidémie du sida. Editions Payot Lausanne
(12) Goffman, E. (1963). Stigma: Notes on the management of a spoiled identity. Englewood Cliffs, NJ: Prentice Hall. (as cited in Brimlow et al.)
(13) Cao, X., Sullivan, S.G., Xu, J., Wu, Z. and the China CIPRA Project 2 Team (2006). Understanding HIV-related stigma and discrimination in a “blameless” population. AIDS Education and Prevention, 18: 518-528.
(14) Ki-Zerbo, G.A., Ramos, F., Viadro, C., Sylla, O., et Coll-Seck, A.M. (2002). Prise en charge psychosociale des personnes vivant avec le VIH: Etude dans le service des maladies infectieuses du CHU de Fann, Dakar, Sénégal. Médecine d’Afrique Noire, Tome 49, N° 3
(15) Yi et al. (2006). Religion, spirituality, and depressive symptoms in patients with HIV/AIDS. Journal of General Internal Medicine, 21: S21-S27
(16) Ba, Mamadou (2007). Guide de Renforcements des Capacités des Tradipracticiens dans la Lutte Contre Les IST/VIH/SIDA. ONG des Tradipraticiens GESTU Depot Legal BSDA N. 13653
(17) Kebe, A.A. (2004). Promouvoir une approche religieuse dans la connaissance et la lutte contre le VIH/SIDA. (unpublished)
(18) Sarr, A.D., et al. (2005). Viral dynamics of primary HIV-1 infection in Senegal, West Africa. Journal of Infectious Diseases, 191: 1460-7.
(19) Campbell, C. and Deacon, H. (2006). Unravelling the contexts of stigma: from internalisation to resistance to change. In: (Eds) Campbell C, Deacon, H. Understanding and Challenging Stigma. Special edition of Journal of Community and Applied Social Psychology. 16: 411-417.
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