HIV/AIDS: An Update, 2004

By Richard L. van Houten

This is the fourth year that I have written on HIV/AIDS at the beginning of the year. Since 2002 we have been reflecting theologically on this question. We have looked at some practical policies that churches could adopt, and we have looked frankly at some of the sexual practices that may contribute to the spread of HIV and other sexually transmitted diseases. Each year we have also summarized some global statistics from the annual UNAIDS report.

The statistics are depressingly similar this year. Last year I noted that three million people died of AIDS, and another five million were infected in the year 2003. For 2004, the UN reports 3.1 million people died of AIDS and 4.9 million were newly infected. No good news here!

Drug treatment for HIV has gone down in cost. Generic antiretroviral (ARV) drugs have reached markets in many places, and most governments support some costs. However, coverage is uneven. Nine of every ten persons who need such treatment do not get it. For that tenth person, however, this news is good.

Global funding and global awareness have increased dramatically since 2001. In 2001 the world spent roughly $2.1 billion on HIV/AIDS, while in 2004, the UN estimates $6.1 billion was spent. Secondary students getting AIDS education has tripled, voluntary testing and counseling have doubled, and women being offered services to prevent mother-to-child transmission has increased 70%. This upward trend is good, too.

Yet more is needed. Voluntary testing has increased, yet only 1% are getting it in the 73 countries most affected by AIDS. Only 3% of orphans and vulnerable children are receiving public support for most services.

Multi-pronged approaches are the only way forward. Prevention efforts are the foundation for this approach, because reduction of HIV infection rates is the only way the epidemic can be reduced. There is no cure. ARV drugs are helpful to prolong life, and this will ease the orphan problem, if parents can survive long enough to see their children reach adulthood with a social support network.

Regional HIV/AIDS statistics and features, end of 2004

* The proportion of adults (15 to 49 years of age) living with HIV/AIDS in 2004, using 2004 population numbers.

The Numbers

All the numbers in the chart are the midpoints of a range. It is difficult to be very accurate about HIV statistics. Last year I discussed briefly the different ways of gathering statistics and the shortcomings of each method. The UN statistics are still the best available.

As has been the case in the past and will be for years to come, the disease is most common in sub-Saharan Africa, with the Caribbean now second in the world’s regions. Across Africa and even within countries in Africa, the numbers vary widely. Southern Africa remains the worst hit area, with South Africa having the most infected people of any country, although its adult prevalency rate is not the highest. Swaziland, Botswana, Lesotho and Namibia, all smaller countries near South Africa, have higher infection rates, with no evidence of declines. In the southern African countries of Malawi, Zambia and Zimbabwe, infection rates appear to be stabilizing at lower rates (16%-25%), still much higher than most of the rest of the world. Most of these countries have churches that are members of the REC, and the challenge of living in these environments are intense.

Life expectancy in these countries is dropping rapidly, and mortality rates are only going to go up in the years ahead, unless major ARV treatment increases take place.

In Nigeria, the overall HIV prevalency rate is about 5%. However, the UNAIDS report singles out two states as having significantly higher rates, Benue State with a rate of 9.3% and Cross River State with a rate of 12%. Each of these states has significant presence by an REC member church.

Uganda continues to report significant declines in HIV infection rates, and stabilizing around 5-6%. A huge educational effort by all sectors of society is usually seen as the major factor in this reduction.

India’s overall rate is relatively low, below 1%, but the UNAIDS report singles out several states with serious epidemics. In Manipur, an epidemic among drug users has spread to the general population, and prevalency rates have risen from 1% to 5% in some cities.

The epidemic in Indonesia remains mostly confined to sex workers and drug users, but it has spread rapidly in the prison population, where random sampling has shown rates as high as 21%.

Women and AIDS

The UNAIDS report dedicated a whole chapter to examining how the epidemic affects women, and why social circumstances make women more susceptible than men to infection. We have touched on this question in previous years, and the UN report confirms some of our previous reporting. Among these is the frequency that younger women have sexual relations with older men, the “sugar-daddy” phenomenon. In addition, the vaginal lining of younger women is more sensitive, more likely to tear during sex, and therefore these young women are more susceptible to viral transfer. However, this report adds other considerations that Christians should pay attention to.

First, what are the facts? When HIV/AIDS is mainly found among drug users and homosexual populations, more males than females become infected. Once the virus spreads among the general population, infection rates among women and girls gradually catch up and pass the male infection rates. In sub-Saharan Africa, 57% of HIV-positive adults are women. The unevenness between men and women is greatest among younger women, aged 15-24, who are three times more likely to be infected than young men of the same age. Let us consider some of the reasons.

Sex and survival

We do not live in an ideal world. If every boy and girl lived with their parents until they either had a well-paying job or married, if everyone could make choices based only on clear moral alternatives, then HIV would probably have a lower impact. However, the reality is that young women have fewer educational and employment opportunities than young men in many societies. Driven by poverty, many young women find that all they have to sell is sex. Even when they do not become ‘prostitutes,’ they may receive ‘gifts’ in exchange for sex, or other goods and services, such as a place to live and some food to eat. Such transactional sexual relations are usually outside of marriage and often with older men who have had multiple sexual partners. Fighting for basic needs, the women in these unequal relationships usually lack the power to demand condom use or HIV testing before sexual activity. The poorer these women are, the more likely they are to fall into such a relationship.

Should Christians condemn such actions? Could not even poor women make proper moral choices in these circumstances? They could. We should not take away moral responsibility from the poor, and we should not just excuse this behavior. At the same time, stern condemnation is also not our best option. The poor choose survival in less than perfect circumstances over not surviving. Making a moral choice when there is little to choose from requires the support of a community. I think we need to take a course that shows pastoral concern both over the difficult circumstances and the moral choices. In such contexts, fighting poverty is a way of fighting HIV.

Sex and social acceptance

I can hardly imagine a society where sexual relations are not part of the social pressure that young men and women place on each other. Sex is a deep drive within all of us. Our societies can counterbalance that drive, and the more organized and cohesive our societies are, the more our sexual drives are channeled into socially acceptable patterns of marriage. But in times of change, when organization and cohesiveness break down, young men and women break the rules, often with the approval and admiration of their peers – until they get caught.

Not only is sex used for status and self-esteem, but also to escape loneliness and boredom. We should not fool ourselves into thinking Christian young people can manage sex because they receive moral education in the churches. It probably has some effect, but may only slightly reduce sexual activity compared with that of their non-Christian peers.

Sex for social reasons becomes dangerous for women when those social patterns are built on gender inequalities. When men have the power, when they are older and more established, and where they have more protection of the law than do women, such sexual activities are riskier for women. Men who have had multiple partners and thus more likely to be infected have a social advantage over more vulnerable women.

Sex and age differences

There is some evidence that the age gap between sexual partners increases the risk for young women and girls. In Zambia a study showed that 18% of women who said they were sexually active for less than a year were HIV-positive. In rural Zimbabwe, teenage girls whose last partner was less than five years older had a 16% prevalency rate, while those whose partners were ten years older or more had a rate twice as high. In Kenya a study found that women whose husbands were less than three years older than they were had no infections, but half of those whose husbands were more than ten years older were infected.

Sex and violence

For how many young women is their first sexual experience a rape, or involving some measure of coercion? Studies from Peru, Jamaica and South Africa suggest ranges between 10% and 25% of all women had experienced rape or violence in their sexual introduction.

Violence within marriage or in longer relationships is also frequently against women. In some societies, whether legally or not, authorities will not prosecute such violence. HIV prevention programs need a component that fights against violence toward women. These are violations of basic human rights. I hope our churches are never looking the other way.

Sex and marital inequality

Age gaps and violence, or the threat of violence, appear within marriages as well as outside of them. A study from Kisumu, Kenya and Ndola, Zambia showed that among sexually active girls aged 15-19 HIV-infection rates were 10% higher among the married women than among the unmarried. In rural Uganda, of infected women aged 15-19, 88% were married. For women who married this young, the chances are that their husbands are older and perhaps had other sexual partners before marriage.

Do they have the right to know? Can they demand their husbands be tested for HIV before marriage and maybe six months after marriage? Can they demand their husbands use a condom if they have strong suspicions that he has been unfaithful? A study in Zambia suggested that only 11% of the women in the survey felt they could even ask the last question.

Churches have some influence in these matters. What should be the church’s policy when a couple asks to be married in the church by a minister? Even after marriage, what role can church councils play? Are they open to receive an appeal from a woman whose husband is unfaithful, and would they support her in protecting herself?

Property and Inheritance

In 2003 I was visiting Nigeria and I stopped in a local congregation of the Evangelical Reformed Church of Christ. One of the congregation’s leaders present was the head of the widows’ society. This church of about 1500 members had 53 widows. The pastor and elders were explaining what they were trying to do for the widows, to help them survive, get food and do some small business to earn money, and to find places to live. I asked why they did not have money and property left from their husband.

By tradition, the husband’s property belongs to his birth family. Parents and brothers of the deceased husband own his house. Sometimes they simply walk into the house and take out all the furniture after the funeral. Other times they evict the widow and her children from the family home. Not all widows faced the same treatment, but it took special circumstances to change. Where husbands made a will giving the property to his wife, the will superceded the traditional family rights.

About that time, Nigerians across the country were registering for a national identity card. One of the questions on the registration was about inheritance. Applicants had to designate a beneficiary for their property if they were to die. Rev. Sunday Emmah, who was my host for that visit, told me that he had written down the name of his wife. The official who took his application stopped him and asked him if that was not a mistake. Should not he have written down the name of his parents or brother?

We continued to discuss this while traveling. When we stopped at the church’s pastoral college in Obi, Emmah asked the students gathered there (both the male pastoral candidates and their wives) about their answers to this question. Only a quarter of the male students had designated their wives. On the other hand, when he turned to the women and asked if they thought they should designate their wives, the answer was unanimous: YES. Emmah suggested the students at the college could start a discussion about this to look at the fairness of this social situation and to see whether they should set a different model in place.

I have not heard whether there was such a discussion. And I do not tell this story to blame those students. These are deeply entrenched social traditions, probably from a different time and society where the rules also provided some protection for a widow. It takes a challenge for all of us to change our traditional ways of thinking about how we relate to the opposite sex. We should be doing this reflection in community. Clearly, the church has some reflection to do about the fairness of traditional property and inheritance customs.

The UNAIDS report also notes that HIV may be worsened by such property and inheritance customs. The payment of a bride price also tightens men’s control over property. In some places women remain legal minors after marriage. Under such conditions it is no wonder that they feel little power to control their sexual relations with their husbands.

A study in Namibia showed that 44% of widows lost cattle, 28% lost small livestock and 41% lost farm equipment in disputes with their husbands’ relatives after his death.

The UNAIDS report suggests that legislation is not enough to deal with these injustices. Government officials will not always enforce such legislation. Beside documentation of property and housing rights, traditional leaders must also become involved. Here, too, I suggest that churches can play a role. Advocacy for the poor and downtrodden lies close to the heart of our faith

Stigmatization

Stigmatization is a convoluted problem. It is a huge hindrance in the fight against HIV/AIDS. Who would reveal he or she is infected if it means rejection and isolation from all you know and love, from your friends, your family, your own children, your church?

Churches have not been at the forefront in the fight against stigmatization. In some cases church leaders have denied the problem. Yes, there is AIDS around, but not in the church, because we have a different morality. We in the churches know there is a moral issue. HIV/AIDS is not a direct punishment for sexual immorality, or many more of us would be infected and dying. Yet, when a person becomes infected, there is some connection with moral transgression, perhaps from the victim, perhaps the victim’s spouse, mother or father. While we want to forgive and welcome the sinner, for that is what we all are, we also want acknowledgment of the sin, because we know that is the way to healing. Such acknowledgment can and should be in the strictest pastoral confidence, unless the victim herself or himself desires to share more fully. Thus, our attitudes, when we have not been in full denial, have shown some ambivalence.

This ethical dimension of stigmatization is just one dimension. The more common aspect of stigmatization is fear: this person has an incurable, fatal disease. If I get too close, I will get it too.

I have touched on stigmatization in several articles on HIV/AIDS that have appeared in REC Focus. Nowhere have we carefully explored it. In December 2003, at a UNAIDS-sponsored theological workshop, the focus was on HIV and AIDS-related stigma. One article by Gillian Patterson I found particularly compelling and helpful, titled “HIV and AIDS: the Challenge and the Context, Conceptualizing Stigma.” She argued that stigma is not a theological concept although it had theological implications. And although it may appear to be a vague and ill-defined concept, she found five ways to look at stigma that help us understand it. Since it is not available to all our readers, I summarize some of her findings here.

Medical Stigma

Stigma is an issue in public health. Borrowing from scholars named Weiss and Ramakrishna, she offered this definition:

Stigma is a social process or related personal experience characterized by exclusion, blame, or devaluation that results from an adverse social judgment about a person or group. The judgment is based on an enduring feature of identity attributable to a health problem or health-related condition, and this judgement is in some essential way medically unwarranted.

Not every exclusion is unwarranted, Patterson pointed out. It is sometimes appropriate to protect health personnel from diseases such as tuberculosis or ebola viruses. It is stigmatizing to continue with such exclusion after the health risk has ended.

The illustration of leprosy is helpful. Before a cure was discovered, lepers had to be excluded from society to control the disease. Now that it is easily curable, there was no reason to continue exclusion. In the 1980s, leprosy control programs made use of the simple message, “Leprosy can be cured.” As more people believed this message, leprosy changed from a condition that transformed your identity to a treatable disease. Stigma died, and people who might not have sought treatment now do.

So the first lesson is: Stigma is related to untreatable diseases. Once treatable, the stigma diminishes.

The weakness of the purely medical approach, Patterson suggested, is that it is scientific and institutional. It may not come to grips with the various social implications of stigma.

Classic Definitions

Patterson next explored the work of Erving Goffman, whose study Stigma appeared in 1963. Originally, stigma were bodily signs. They were brands or marks cut into a body to show that person was a slave, criminal or traitor. These were blemished persons, to be avoided, especially in public.

Ultimately, stigmas are about relationships. A free person may stigmatize a slave, but another slave will see that slave as an equal, one to be accepted. These are one’s ‘own,’ the clan where one can be free to share his or her story. Another group, whom Goffman called the ‘wise,’ were ‘normal’ people who had a special relationship of acceptance toward the stigmatized, and they could be accepted into the ‘own’ group. The ‘wise’, however, sometimes end up sharing the stigma with the group, such as, doctors in leprosy settlements. So a stigmatized person has waves of relationships, with varying intensities of pain.

Sometimes the stigmatized condition is obvious. Sometimes it is forced, as the yellow star the German Nazis forced Jews to wear. When it is invisible, the question for the victim is whether or not to tell. Victims need to manage the selected disclosure of information.

When victims choose to disclose, they usually have to choose to accept society’s stereotypes. They are supposed to feel grateful for being accepted at all. Usually, the ‘normals’ will not admit to the unfairness of their attitudes.

Goffman noted that wherever there is something normal, there will also be deviations. That is true by definition. A consensus about normal is built on a consensus on what is not normal. Secondly, social attitudes about stigma can and do change. Think about shifts in attitudes toward divorce, mental illness and homosexuality.

Sectarianism as stigma

Patterson devoted a section of her paper to stigma arising from areas divided by religion, such as Northern Ireland. Although some individuals do not participate in the stigmatizing actions and attitudes, they cannot change the stigmatization just by changing themselves. A Protestant who befriends a Catholic in Northern Ireland changes only a little the pervading sense of the Catholic that he or she is a second-class person there. The marches and protests and ugly language continue, even though she has a friend from the other side.

Stigma does not require a direct response from us for it to continue. Only that we do nothing.

Purity

Some in the anti-AIDS struggle appreciate the work of Mary Douglas, who wrote on purity and danger, pollution and taboo.

When society stigmatizes and excludes, Douglas wrote, it is trying to protect itself and ensure its survival. The stigmatized person has polluted the community and become a danger. Societies that use purity standards have the same rules for goodness or holiness and uncleanness. Dirty is bad; clean is good. If a clod of dirt falls into your drinking water, the water is muddy. It is useless to ask how it happened or who is at fault. The water is impure.

The caste system in India is an example of such stigmatization. The purer Brahmin caste must keep clean, so its members have nothing to do with sanitation. Lower castes must take care of waste and manage the animals. Just doing so keeps them impure. They have touched things the Brahmins have not touched, and now they are ‘untouchable.’

“A polluting person,” wrote Douglas, “is always in the wrong.” He crossed a line or developed a condition that is a danger for others.

Sex is particularly explosive for societies concerned about pollution. Societies make rules for managing social relations, usually by controlling sexual behavior outside of marriage. Many people violate them, but only some get caught. These are ‘sinners’ who are now judged by the others who were not caught. I think most of our societies at one time valued a woman’s virginity higher than a man’s, and a woman who had sexual relations before marriage was polluted somehow, even if the sex was involuntary on her part.

Christ brought an end to such purity concepts, although the Christian Church has not been able to follow. Christ no longer judged people on how pure they were. Peter was told in a vision to reach out to Gentiles, that what God made is not impure. We have resources in the Christian faith to challenge notions of purity and pollution, and these are important tools in our struggle against HIV/AIDS.

Stigmatization and Power

Stigmatization shares with racism and other forms of discrimination its link with power. Those in power define what is acceptable and what it not. Stigmatization may become a tool the powerful ones use to subdue potential threats to their power. If those in power can persuade the stigmatized to accept the dominant view, the stigmatized group will be less inclined to resist the restrictions on them.

The truth of this is illustrated by thinking about powerless groups. Bruce Link and Jo Phelan gave the example of mental patients in a treatment program. All the patients might label certain health workers as a pill-pusher or as arrogant and demanding, but the staff will not end up being a stigmatized group. That patients are powerless to spread their point of view outside of their group.

The Christian Church should be sensitive to the use of power. We have used and misused it. What power we have, we need to turn to bring the liberating force of the gospel to the powerless. In this as in other matters, we must follow Christ.

Conclusion

Our discussion about HIV/AIDS over the last few years will be continued at the REC Assembly in July 2005. We will only be able to do a little there, but we hope that the leaders of our member churches gathered there will be able to find some ways to help the gospel bring healing to the victims of this epidemic.

Reference: REC FOCUS – Vol. 5 No. 1 March, 2005. IV/AIDS: An Update, 2004

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