How Can Faith-Based Organizations Help Address the HIV/AIDS Epidemic in Central America?

HIV/AIDS in Latin America has been called “the overlooked epidemic” because it has been overshadowed by epidemics of larger scale and severity in sub-Saharan Africa and Asia. Although AIDS accounts for a relatively small fraction of all adult deaths in most Latin American countries, the economic effects can be large because AIDS tends to strike adults in the most productive years of life. Addressing HIV in Latin America has thus been described as an opportunity to prevent epidemics as devastating as those of sub-Saharan Africa and to apply lessons learned from Africa and Asia. However, to date, government efforts to address the epidemic have fallen short of the levels needed to provide effective prevention and widespread access to treatment.

Faith-based organizations (FBOs) have historically played an important role in delivering health and social services in developing countries. FBOs include religious congregations and coordinating bodies as well as faith-based (denominational, interdenominational, or interfaith) nongovernmental organizations (NGOs) that engage in community health activities. Given the limitations in public health infrastructure and resources available to address the epidemic, it is natural to ask what role FBOs currently play and might play in the future in addressing HIV/AIDS. At the same time, there are potential challenges to FBO involvement, including FBO policies that alienate those subpopulations most at risk or most affected and FBO policies that restrict the range of strategies that can be employed to address the epidemic (e.g., prohibitions of condom use).

A team of RAND researchers sought to shed light on these issues by examining the current and potential future role of FBOs in HIV prevention and care in the three Central American countries that, at the time the study began, in 2007, had the highest HIV prevalence: Belize (2.5 percent), Honduras (1.5 percent), and Guatemala (0.9 percent). The study identifies several areas in which FBOs might enhance their involvement, including provision of care and support services for HIV patients, stigma reduction within the faith community, and advocacy. Collaboration with other organizations is key to many of these roles.

FBO-Sponsored Activities Occur Along a Continuum of HIV/AIDS Care

To examine the scope of current and future HIV/AIDS activities in which FBOs might be involved, the RAND team developed the framework shown in the figure. The figure divides HIV/AIDS activities into several phases, which correspond to an individual's position on the continuum of HIV/AIDS care: prevention, testing, and care and support services (the latter of which is divided into pastoral care and social support, hospice care, and medical care and mental health treatment). Stigma reduction and advocacy activities are conceived of as spanning all the phases, i.e., they can be aimed at increasing an individual's participation in prevention, testing, or care and support activities.

To understand the nature of the need for HIV/AIDS care and support in the study countries, the researchers first sought to characterize the scope of the epidemic. Across the three countries, HIV affects mostly young adults, men who have sex with men, and sex workers. In Honduras and Belize, the Garífuna peoples, descendants of African slaves, are also highly affected. Women in general represent a growing portion of the HIV-positive population. In all three countries, but especially Guatemala, HIV/AIDS care is not widely available in the health system, and hospitals and health care personnel with experience in HIV are centralized mainly in capital and major cities. In general, there is greater emphasis by government on treatment than on prevention, although the need to sustain antiretroviral (ARV) coverage over the long term has not been addressed. Discrimination and stigma also pose considerable problems.

To Date, FBO Activities Have Focused Mostly on Care and Support

RAND researchers conducted key informant and stakeholder interviews with health and FBO leaders in the three countries, as well as site visits to FBO-sponsored HIV/AIDS clinics, hospices, programs, and other activities. The study found that many FBOs are already engaging in some activities related to HIV prevention and testing, care and support services, and stigma reduction and advocacy.

Care and support services. A relatively large number of FBOs, especially in Guatemala and Honduras, have been involved in providing hospice care or shelter for people living with HIV, although these facilities range considerably in size and quality. FBOs in all three countries, including congregations and faith-based NGOs, are also involved in counseling, prayer, care for the dying, support groups, and other forms of pastoral care. In contrast, very few FBOs focus specifically on improving the social and economic well-being of people living with HIV (e.g., through formal assistance with food and nutrition or income generation).

Religious congregations were not often involved in providing medical or mental health care. However, a few faith-based NGOs provide such services as clinical care management, administration of ARVs, and treatment of opportunistic infections.

Stigma reduction and advocacy. Some FBOs are involved in stigma reduction activities, including solidarity marches, sermons, workshops, and interactions with family members. Some also engage in advocacy, such as promoting the human rights of people living with HIV/AIDS, providing education about their workplace rights, advocating for treatment access, and preparing religious leaders to train others in their congregations to carry out HIV prevention and care activities.

Prevention and testing. To date, FBOs have had limited involvement in HIV prevention. Most FBO prevention activities focus on education for children and youth, and very few are directed toward high-risk, highly stigmatized populations, such as men who have sex with men or commercial sex workers. FBO leaders have widely varying attitudes on condom use, though the majority of FBO leaders interviewed were either anti-condom or willing to mention condoms only in specific circumstances and for limited purposes (e.g., for sero-discordant couples). A few FBOs have started to offer rapid HIV testing (saliva and blood), both to the general population and to high-risk groups.

Though FBOs Have Broad Reach, Barriers Can Hinder Involvement in HIV/AIDS

The RAND team's interviews with health and FBO leaders provided insights into the advantages of FBO involvement in HIV, as well as challenges to FBO involvement.

Advantages

Broad reach and influence. There was an overall sense among interviewees that FBOs in the three countries could leverage their broad reach and influence to raise awareness and decrease stigma toward people living with HIV and AIDS and to provide support and care, particularly where gaps exist, e.g., by assisting people living with HIV with nutrition or income generation. Some health and most FBO leaders noted that FBOs' influence among youth and in remote areas could help them raise awareness and spread prevention messages.

Challenges

FBO attitudes and beliefs. Judgmental attitudes on the part of FBOs toward gays, men who have sex with men, and commercial sex workers and their limited reach into these groups were seen by health leaders as significant challenges to FBO involvement in supporting people living with HIV. Health leaders were also concerned about FBO leaders' tendency to interpret HIV in religious terms. HIV prevention efforts have been further impeded by FBO leaders' difficulty in discussing sex as well as FBO prohibitions against condom use and/or reluctance to promote condoms.

Organizational barriers. A number of health leaders noted that there is no one structure that brings together all faith groups, and this makes it hard to coordinate more broadly with this sector. This challenge can be further compounded by the multiculturalism of the population.

Resource barriers. FBO leaders emphasized that many churches do not have resources for HIV/AIDS activities. They also noted that although churches exist in nearly all geographic areas and communities, health care resources do not, making coordination with health care providers in rural areas difficult.

Disagreements and tensions between FBOs and secular health organizations. The interviews revealed fundamental differences in values between religious and health leaders that have limited their ability to work collaboratively. Most important, many religious leaders promote particular prevention methods (such as abstinence or “being faithful”) and oppose others (such as condom use) based more on their religious beliefs than on evidence of each method's effectiveness. In contrast, health leaders favor prevention methods that have been proven effective in preventing HIV transmission.

Opportunities Exist for Greater FBO Involvement

Based on the findings from the interviews, the RAND team identified several potential roles for FBOs in addressing HIV/AIDS in the three countries.

FBOs might take a larger role in prevention and testing, in partnership with public health providers. It is unrealistic to expect many FBOs to shift their focus toward high-risk populations and promotion of condom use. Nonetheless, there is still a lot that FBOs could do in the fight against AIDS — e.g., by encouraging people to get tested and get information about HIV — particularly because churches exist in all communities. FBOs that provide testing in partnership with public health providers can send a constructive message that HIV is a disease for which treatment is available and that people should know their status.

FBOs might become more involved in providing care and support services. FBOs already provide many services of this sort. These activities might be expanded to include other needed services that are rarely addressed, such as transportation, food, housing, and income-generating activities.

Certain FBOs seem uniquely qualified to undertake stigma reduction activities both within the faith community and the broader population. In view of FBOs' moral authority, broad reach, and ability to influence attitudes, stigma reduction is an area in which FBOs could have an especially strong impact.

Advocacy is another area in which the role of FBOs might be expanded. Some FBOs have assumed an advocacy role for people living with HIV, advocating for greater access to health care, ARVs, or workplace rights. These efforts can be quite important in countering the effects of discrimination or simple lack of attention.

Collaboration with Other Organizations Is Needed

There is a need for greater recognition among health and FBO leaders of the unique and complementary strengths that each sector can provide to the fight against HIV/AIDS. There are several activities that FBOs can undertake in collaboration with the health care system:

• Complement the activities of other organizations by addressing gaps that others are unable to address, e.g., by establishing housing projects and hospices or facilitating income-generating activities.
• Reinforce the activities undertaken by other organizations, e.g., by emphasizing prevention messages, counseling congregations on safe sex, or encouraging people to get tested.
• Facilitate the activities of other organizations, e.g., by offering opportunities for health leaders to promote the use of condoms in conjunction with other activities that FBOs are directly responsible for organizing.
• Support the activities undertaken by other organizations, e.g., by recognizing the efforts of others and encouraging people to support other organizations' programs.

The findings of this study suggest that leaders in the public health sector might find it worthwhile to think creatively about ways to make effective use of the strengths and capabilities of FBOs in addressing some of the critical needs posed by the HIV epidemic. Donor organizations can also play a critical role in fostering collaboration between FBOs and public agencies by providing funds with which to evaluate and sustain such partnerships.

Topics

• Global Health
• Guatemala
• Health, Health Care, and Aging
• HIV and AIDS
• Honduras
• Sexual Behavior
• Sexually Transmitted Diseases