HIV/AIDS PREVENTION STRATEGIES WITHIN A CATHOLIC NGO IN TANZANIA

The HIV/AIDS epidemic has proven to be an increasing health challenge in sub-Saharan Africa since its onset almost three decades ago. Due to the magnitude and impact of the epidemic, many actors have gotten involved in overall HIV/AIDS response efforts. Faith-based organizations (FBOs) in particular are increasingly becoming involved. FBOs' involvement has included the provision of care and support for people living with HIV/AIDS (PLWHA); HIV prevention and education; support of orphans and vulnerable children; and advocacy and rights (ARHAP 2006; Parker and Birdsall 2005). As a result, FBOs are recognized as significant players in the overall response to HIV/AIDS (Olivier et al. 2006; Tiendrebeogo and Buyckx 2004).

FBOs are in a unique position to influence HIV/AIDS response efforts, both at the community and national levels, due to, for example, their ability to reach large numbers of people through existing networks; the trust and respect they enjoy within their communities; their regular contact with their members and followers; and their influence and moral authority over issues closely connected to HIV, such as personal behavior, beliefs about disease causality and prevention, and rules about sexual activity and family life (Liebowitz 2002; Parker and Birdsall 2005). At the same time, however, FBOs' nature as moral- and value-based institutions, with direct “jurisdiction” and authority over such issues, is often viewed as an obstacle to HIV/AIDS prevention and mitigation efforts due to their sometimes restrictive prescriptions which can lead to stigma and discrimination of PLWHA. The faith-based response to HIV/AIDS, however, is diverse, influenced by a number of interrelating factors, including religious doctrine, notions of ethics and morality, the socio-cultural environment, biomedical discourse, availability of resources, and locally identified needs (Casale et al. 2010; Morgan, Green, and Boesten 2013; Parker and Birdsall 2005; Tiendrebeogo and Buyckx 2004).

The theological and health challenges inherent in issues surrounding HIV/AIDS and sexual behavior have meant that the faith-based response to HIV/AIDS prevention has been both varied and controversial (Casale et al. 2010). HIV/AIDS deals with contentious and sensitive issues, such as sexuality, sexual activity, gender, and family life. Many prevention issues pertinent to HIV/AIDS, like the promotion of condom use, sex outside of marriage, and the prevention of HIV among high-risk and vulnerable groups like men who have sex with men (MSM) and commercial sex workers (CSWs) are issues that often clash with religious doctrine. At the same time there are a variety of different types of FBOs, such as churches, development organizations, and missionary organizations, for example, and the influence of religious doctrine on HIV/AIDS prevention efforts within these organizations varies considerably (Berger 2003; Casale et al. 2010). Faith-based non-governmental organizations (NGOs), or service delivery organizations, in particular, can be put in a difficult position as a result of this clash.

This article describes the HIV/AIDS prevention strategies implemented by staff within a Catholic NGO in Tanzania in response to this clash, and explores reasons for the probable existence of this clash. Strategies included distinguishing between condom “education” and “promotion,” emphasizing individual choice, and framing issues in a way that circumvented religious moral or ethical arguments. These findings are part of a larger study that explored the factors influencing the HIV/AIDS prevention policy process within faith-based NGOs of different faiths within Dar es Salaam, Tanzania (Morgan 2011). The paper begins by describing the data collection methods used and the organizational context. Next, the three strategies used and their operationalization within the organization are examined. The article concludes by situating the organization and the strategies used within a larger context of FBOs and HIV/AIDS prevention.

Methods and Organizational Context

This article presents findings from a wider study exploring the HIV/AIDS policy processes of faith-based NGOs (Morgan 2011; Morgan, Green, and Boesten 2013). The research used a qualitative, comparative case-study approach and employed Walt and Gilson's (1994) health policy framework, which examines context, actors, process, and content, and how they interrelate within the policy process. Data collection took place from June 2009 to November 2009 in Dar es Salaam, Tanzania. Twenty-four interviews were conducted at the Catholic organization, along with document review and observation. Interviewees were chosen based on their role within the organization, the number of which was informed by the number of key informants within the organization. Respondents were asked about the factors involved in decision-making within the HIV/AIDS prevention policy process. Framework analysis was used to analyze the data (Ritchie and Spencer 1993; Spencer, Ritchie, and Connor 2003). Using the analysis steps outlined within framework analysis (such as indexing, charting, mapping, and interpretation), HIV/AIDS prevention strategies emerged as an important theme within the data after examining and comparing the different themes (and their inter-relationships).

Ethical approval was granted from the Leeds Institute of Health Sciences Ethics Sub Committee and the National Institute for Medical Research in Tanzania. In addition, research clearance was granted from the Commission for Science and Technology in Tanzania. All participants received detailed information about the study, were informed that their participation was voluntary, and signed a consent form prior to participation.

The Catholic organization can be described as a professional organization which had a clear organizational policy regarding HIV/AIDS prevention. The organization employed over 100 professional staff (such as doctors, public health specialists, nurses, and counselors) from different religious denominations. At the same time, the organization was expected to follow the mandate of the Catholic Church, which at the time of data collection did not permit condom promotion under any circumstance, promoting instead faithfulness and abstinence. Due to the professional nature of the organization, actors had varying beliefs regarding the role of condoms in HIV/AIDS prevention. Some respondents, for example, agreed with the Catholic Church, either due to their own personal beliefs or because they questioned the effectiveness of condoms, while others disagreed with the position of the Catholic Church as a result of their position as a medical professional.

Despite this, the importance of not going against the position of the Catholic Church was emphasized by all respondents. The challenge of working within an organization that does not promote the use of condoms, however, was a common theme throughout the interviews, particularly with those who viewed condoms as an important part of HIV/AIDS prevention work. The HIV/AIDS prevention strategies operationalized within the organization were a result of this challenge and the strategies were used by respondents in order to ensure that their HIV/AIDS prevention approach was not only in line with their own understanding of HIV/AIDS, but that it did not overtly go against the position of the Catholic Church.

The Catholic organization provided a range of services, which included both care and support of people infected and affected by HIV/AIDS, as well as preventative services. The organization's main prevention services can be divided into three categories: (1) HIV/AIDS prevention at the community level; (2) positive prevention; and (3) HIV/AIDS prevention among vulnerable groups. Community HIV/AIDS prevention at the community level is targeted at people within the community who are HIV negative or do not know their HIV status, particularly youth and pregnant women, with the overall aim of preventing new HIV infections. Positive prevention is targeted at HIV-positive clients, with the aim of preventing PLWHA from being infected with a different strain of HIV (re-infection) or infecting others. And HIV/AIDS prevention among vulnerable groups is targeted at those groups who are particularly susceptible to HIV infection due to lifestyle circumstances or choices, such as CSWs, MSM, and youth, with the aim of preventing HIV infection. The strategies are discussed in relation to these three areas of HIV/AIDS prevention.

HIV/AIDS Prevention Strategies

Many respondents saw it as their professional duty, regardless of their personal beliefs, to provide all HIV/AIDS prevention options to communities, including information about condoms. In addition, according to respondents, they were permitted by the Catholic Church to educate about condoms but not promote them. As a result, a distinction was made between condom promotion and education:

We talk about the facts about condoms and then we leave it there … We are not promoting but we talk about condoms. (Respondent #21)

I'm a health professional, a Tanzanian trained, I was trained by the government initially, [the organization] trained me also, and I might be obliged to talk about condoms, and maybe the government would like me to promote condoms … I know facts about condoms, I know people use condoms, but it's not my duty to tell somebody use a condom. I see my role here is to give the correct information about the condom, the use of condom, but not tell somebody, please use a condom. It's up to her or him to decide … The Catholic Church doesn't prevent me from giving the education about condoms. (Respondent #20)

By talking about condoms (giving the facts about condoms), but not promoting them (telling an individual to use a condom), respondents felt that they left the choice of whether or not to use a condom up to an individual, a theme which will be discussed in greater detail below. Respondents therefore felt that while they were not actively going against the position of the Catholic Church, they were meeting their professional obligations by ensuring that condoms remained an HIV/AIDS prevention option.

The issue of condom promotion was particularly contentious with regards to positive prevention. In the context of discordant couples—where one partner is HIV positive—there are really only two options for HIV prevention—to abstain from sex or to use a condom. Respondents recognized the difficulty of such cases, particularly in relation to the Catholic Church, which at the time of data collection did not advocate the use of condoms in any situation. With regards to discordant couples in particular, many respondents disagreed with the Catholic Church's position on condoms, and questioned the rigidity of the Church with regards to this issue. Some respondents, for example, questioned the Catholic Church's fixation on condoms as a form of contraception as opposed to a mechanism of saving people's lives, and wondered if it was appropriate in today's context, as demonstrated by the following two responses:

It's an issue which is being debated all over the world within the Catholic Church, because it has nothing to do here with contraception, which is the basic stance, why the Catholic Church is basically against the use of condoms. It's to do with saving lives, it's to do with avoiding killing people, which is also part of the ethics of the Catholic Church. The issue is, each person has to individually, according to their own conscience, find their balance between those two conflicts, but personally I would say don't kill and don't infect other people. (Respondent #19)

When it comes to that [discordant couples], it's another issue. You see, the one who is positive has got a possibility of killing the other one who is not. So if our intention is to not kill people, that we could introduce condom somewhere, it makes sense somewhere. (Respondent #10)

It is clear in the above two quotations that these respondents felt discordant couples were an exceptional case that should be recognized by the Catholic Church. As such cases were yet to be recognized, strategies were employed by respondents to ensure clients were adequately protected against HIV, while not overtly going against the position of the Catholic Church.

Through education on condoms, for example, respondents could impart their technical knowledge about condoms without influencing the client's decision. By doing so they left it up to the client to choose the most appropriate form of HIV prevention. The following quotation exemplifies not only the difficult position respondents felt they were in with regards to discordant couples, but also the distinction made between condom education and promotion:

The issue of discordant couples is a very difficult issue, especially for Catholics. It's clear that, for example, you have in front of you a discordant couple, your main message is, ok let's try to keep the negative partner negative, and at the same time protect the person who is HIV positive. So the issue and the advice and the counselling that is given is based on this. Then of course that couple will say to you, ok what do we do? So you know your options are limited. Because either you stop having sex completely, so abstinence, or you protect yourself with the use of a condom. And that explanation is given. And then each couple, each individual has to make their own decision about what they're going to do … So you know the advice might be, ok this is the technical advice I can give you and you have to see according to your own religion, your own faith, your, what you want to do, and we leave it up to the individual. (Respondent #19)

As the above quotation suggests, respondents would use their position as a professional to provide technical advice about HIV/AIDS prevention, leaving the choice of whether or not to use a condom up to the individual. Emphasizing individual choice was another way respondents were found to mediate between their own professional beliefs about HIV/AIDS prevention and the position of the Catholic Church. The following quotations exemplify both the distinction made between condom education and promotion, and the emphasis placed on individual choice:

When we are meeting with the community, the level of the community, they ask many questions about condoms, about how to protect themselves. We are giving them all the ways of protection, but not telling them exactly what to do, because the decision to do something is from the person, so we are telling them, the way, the good way to protect yourself is maybe to use condom. (Respondent #22)

We do provide information. And we normally share with them, so it is a matter of her or them to have a choice. But we talk about the facts about condoms and then we leave it there. (Respondent #21)

The notion of individual choice was often associated with the distinction between condom promotion and education. By emphasizing individual choice, the responsibility to decide whether condoms were an appropriate or effective prevention tool is placed in the hands of the individual. By not promoting or discouraging condom use, for example, one would not be held responsible if an individual went against the Catholic Church by choosing to use a condom, or put themselves at risk by choosing not to use a condom. In such cases, if an individual indicated that they would like to use a condom, they would be referred to organizations that distribute them.

Another strategy used by respondents to mediate between the two positions was to circumvent religious moral or ethical arguments by framing HIV/AIDS prevention as a health issue as opposed to a religious one, in an attempt to ensure that an individual did not put themselves or others at risk of infection. This strategy is exemplified by the following two quotations:

I remind them as a Catholic, about the risk they're having on their health. So what do they prefer? To get HIV or to live safe? Putting aside their beliefs and faith. So it depends. If they say ok, we want to use condoms, I just refer to where they can get more information about condoms … If somebody says no I'm not going to use a condom, of course I show the risk they are having, the risk he's having. (Respondent #10)

Although I believe condoms may help you, I'll twist my question in such a way that the patient himself thinks that or says that maybe it's good that I use a condom. So I ask how are you going to use it? What things should you consider before using it, to make sure that you don't get the virus? So there is a little of, twisting the question instead of filling in for the patient, then you twist the question so that a client really chooses it, and then you probe on his knowledge about it. (Respondent #15)

In both examples, the respondents found ways to mediate between two conflicting positions: their own professional understanding of HIV/AIDS prevention and the Catholic Church's position on condoms. They would present the issue in a way that circumvented religious moral or ethical arguments, focusing instead on the health risks associated with not using a condom, attempting to influence individuals to make a decision that did not put themselves and others at risk.

This theme was also evident with the organization's work with vulnerable groups. At the time of data collection, the organization had recently begun working with MSM for money, having already worked with one group of about 20 men with plans of targeting more in the future. MSM were first recognized as a vulnerable group by an employee who identified them through his work within the community, and then approached the department head and Director for support. After support was granted, a course was conducted which focused on fostering positive life skills, and encouraging the men to stop engaging in “at-risk” practices. Each participant was also encouraged to test for HIV; out of the 20, 11 were found to be HIV positive. According to respondents, this high prevalence emphasized the importance of working with this group.

Despite this, it was recognized that working with MSM remained a contentious issue due to the Catholic Church's condemning stance on homosexuality, and the fact that MSM was a highly sensitive issue within the Tanzanian context, being both stigmatized and illegal. In order to continue working with this group, it was therefore important for the organization to receive support from the Bishop. The Bishop was only approached after the initial group of MSM had been tested and the prevalence rate of over 50 percent was found, information which was used to stress the importance of working with this group:

[After] explanation, the rationale, the output, the methodology, how it will be conducted, [the Bishop] agreed [to allow the organization] to go on preparing such a project. If he said no, then we would not proceed with it. (Respondent #14)

In seeking the Bishop's permission, respondents emphasized the importance of how the issue was framed. It was recognized, for example, that within the overall group of MSM, there were two sub-groups—heterosexual MSM for money and homosexual MSM for money, as exemplified by the following quotation:

Within this group of men there were two sub-groups. One is men, young men, who are male commercial sex workers purely because they have no other way of living, just as women go into commercial sex work, they do it themselves because they need to earn a living and they have no other, they don't have schooling, or they don't have access to other employment. And then the other sub-group are those who are actually homosexuals. (Respondent #19)

Despite there being two groups, the group was defined as male CSWs who have sex with men; sexual practice was therefore placed above sexual orientation and homosexuality was not referenced, which may have contributed to these men's decision to work with the Catholic NGO. Regardless of the men's sexual orientation, they were viewed to be engaging in commercial sex work as a result of their environment (not their sexual orientation), and working with this group was seen as a way of empowering them to leave this behavior. Due to MSM being highly stigmatized within the community, it was also recognized that many of these men's clients would be married with children, and would bring HIV/AIDS home to their families if they were to be infected. By targeting MSM, respondents also saw it as a way of reaching these men's families. Many respondents also justified working with this group by recognizing the “reality of the situation”—it was a problem within the community that needed to be addressed, particularly as sex is a major transmitter of HIV, and MSM are a particular source of HIV infection. The issue of MSM was therefore framed in a way that circumvented religious moral or ethical arguments to put the health of the men, their clients, and the clients' families first.

Discussion

While FBOs play a large role in HIV/AIDs prevention efforts in sub-Saharan Africa, the faith-based response to HIV/AIDS prevention varies, influenced by a number of different factors (Morgan, Green, and Boesten 2013). The strategies used by actors within the Catholic NGO influenced its overall HIV/AIDS prevention response and can be interpreted as a compromise made by actors to rectify the tension between what they felt was their professional duty and the directives of the Catholic Church. Although the tensions discussed within this paper were found within one Catholic NGO, due to the number of FBOs responding to the HIV/AIDS epidemic, it is possible that similar tensions exist within faith-based NGOs with comparable attributes, affecting their overall HIV/AIDS prevention response. Similar tensions (and strategies) may even exist within secular NGOs in countries with strong levels of religiosity where actors hold religious beliefs that conflict with the policy or position of the organization in which they work.

According to Casale et al. (2010, 142), it is “useful to identify the tensions that may subtly affect HIV prevention work, or to consider them as models for thinking about similar complexities among other FBOs or faith-based HIV prevention in general.” It is clear that tensions between professional ethics and religious directives affected the organization's overall HIV/AIDS prevention work. The existence of such tensions can be understood in relation to the organization's professional NGO identity, the role that faith plays within it, and its relationship with the Catholic Church.

Faith-based NGOs, for example, are a specific type of FBO which can be distinguished from churches or missionary organizations. They are defined as formal professionalized

organizations whose identity and mission are self-consciously derived from the teachings of one or more religious or spiritual traditions and which operate on a non-profit, independent, voluntary basis to promote and realize collectively articulated ideas about the public good at the national or international level. (Berger 2003, 16; see also Benedetti 2006)

The role of faith will differ between different types of FBOs, affecting an organization's overall HIV/AIDS response.

The influence of faith within FBOs is said to lie along a continuum from being a secondary or tertiary consideration for action to being the principal consideration for action (Benedetti 2006; Clarke 2008; Sider and Unruh 2004). For organizations where it is a secondary or tertiary consideration, faith plays a relatively passive role, where it becomes subsidiary to broader humanitarian principles, playing an indirect role in motivating and mobilizing staff and supporters (Clarke 2008). For organizations where it is a principal consideration faith will play more of a persuasive role, providing an important role in motivating and mobilizing staff and supporters, often aiming to bring new converts to, or advance the interests of, the faith (Clarke 2008). Within the former, staff will often be recruited based upon their skills and expertise over their religious affiliation, whereas within the latter religious affiliation will often play a large role within recruitment. Within the Catholic NGO, faith therefore appears to play a secondary or tertiary role, subsidiary to broader humanitarian and ethical principles; for some actors, it even appeared to be an obstacle that needed to be overcome.

At the same time, the organization is directly affiliated with the Catholic Church within Tanzania, and was originally created by members of the Church. According to Denis (2009, 69), while faith-based NGOs are “the visible face of the church's response to HIV/AIDS,” they maintain a degree of separation from the Church and may in fact operate in contradiction to the directives of Church leaders. While a degree of separation was evident, it was clear that the organization was not allowed to go overtly against the directives of the Catholic Church, and the actors were careful to not be seen as doing so for fear of repercussions. Despite this, due to the professional nature of the organization, Catholic Church directives were found to conflict with the professional responsibility felt by actors with regards to HIV/AIDS prevention. HIV/AIDS prevention created a dilemma for many respondents, as they saw it as an ethical issue as opposed to a religious one; it was about saving lives as opposed to procreation or the condemnation of sinful behavior. This therefore created a tension between professional ethics and religious doctrine within the organization.

Other studies have explored the tensions that exist within FBOs (Arend 2008; Casale et al. 2010); however, the tension between professional ethics and religious doctrine was not recognized. Evidence on the role of professional ethics (or professionalism) in FBOs within the literature is lacking. While examples can be found of Christians (including Catholics) actively promoting birth control or condoms, much of this evidence is anecdotal and not attached to specific FBOs, and it is difficult to know whether this is the result of personal or professional beliefs. The lack of such evidence may be the result of the sensitive nature of the HIV/AIDS prevention and the relative power that the Catholic Church holds.

The organization's professional NGO identity, the role that faith plays within it, and its relationship with the Catholic Church can help to explain the tensions found within the organization with regards to HIV/AIDS prevention, and the strategies used by actors to mediate these tensions and circumvent the directives of the Catholic Church. This case study adds to the existing literature about faith-based response efforts, highlighting some of the factors that affect faith-based NGOs' HIV/AIDS prevention work. What is evident from this case study is that FBOs are influenced by a number of interrelated (and sometimes conflicting) factors which affect their overall HIV/AIDS prevention response. Understanding what these factors are, how they interrelate, and how actors respond to them allows us to recognize the tensions that exist within FBOs and develop a better picture of the overall faith-based response to HIV/AIDS prevention.

Additional information

Rosemary Morgan is a lecturer in Global Health Policy for the Global Public Health Unit (GPHU) at the University of Edinburgh and an honorary fellow at the Nuffield Centre for International Health and Development at the University of Leeds. She holds a PhD in International Health and Development from the University of Leeds, an MSc in Policy Studies from the University of Edinburgh, and a BA in Sociology from the University of British Columbia.