The latest news on AIDS in sub-Saharan Africa, the epidemic’s epicenter, is good. New HIV infections have declined by 25 percent since 2001, AIDS-related deaths have decreased by 32 percent over the past 6 years, and there are expanded options for testing and treatment. After decades of doom-and-gloom news about AIDS in Africa, optimism is finally in the air.
What’s behind this positive turn? The standard narrative attributes these recent improvements to Western engagement. The heroes are the best-known acronyms in the world of AIDS (PEPFAR, UNAIDS, WHO), the Global Fund, and a host of NGOs. Together, these organizations have waged total war against AIDS in Africa—or what looks like total war if you compare it to efforts devoted to other diseases. They have spent tens of billions of dollars. They have mobilized legions of scientists, medical professionals, development workers, educators, TV programmers, marketing specialists, and volunteers. And they have shunned, silenced, and demonized those who oppose their good work. The good news about AIDS in Africa—so this standard narrative goes—is the result of their efforts. It’s proof that even on that dark and desperate continent, awash with ancient superstitions, hypersexuality, dangerous traditional practices, and poor leadership, AIDS cannot withstand a sustained pummeling by well-intentioned and well-financed outsiders.
This narrative contains some important elements of truth: Pharmacological treatments in particular are transforming HIV from a death sentence into a manageable, chronic condition, at least for those with access to antiretrovirals. But most of the measured improvements in AIDS in Africa are actually the result of cumulative, widespread behavior change that has led to a reduction in new HIV infections. In other words, the standard narrative is wrong.
The narrative is wrong because it ignores local African responses to AIDS and characterizes religion and religious leaders as part of the problem. We have systematically studied the role of religious leaders in sub-Saharan Africa for about a decade. As a single class of people, local religious leaders sit at the very top of our list of who should receive credit for the behavior changes that have curbed the spread of HIV in Africa.
This statement may surprise or even irritate people imagining fire-and-brimstone preachers who condemn the use of condoms, push conservative messages about sex and morality, and interpret AIDS as God’s wrath. That’s not what African religious leaders have been doing—quite the contrary. Yet their story remains untold.
Approximately 90 percent of Africans participate regularly in some religious congregation, and religious leaders have been preaching about sexual morality, in particular about abstinence and fidelity. But Africa’s religious leaders began doing this before PEPFAR and Western public health authorities told them to—long before the attention of the development world turned to AIDS in Africa. What prompted their efforts? Certainly not the fact that they were, or are, getting paid to do this by foreign NGOs. Ninety percent of congregation leaders in Malawi, where we began working on AIDS in 2004, have never seen a penny from any international NGO or their programs. Rather, they started preaching and teaching and facilitating conversations about AIDS when they became overwhelmed with caregiving and burial responsibilities, and when their members—especially the women—began demanding that they do so.
Local religious messages about abstinence and faithfulness are, at their root, moral messages, but not exclusively so. For nearly two decades, religious leaders of various stripes in Malawi—a religiously diverse country with high HIV prevalence—have been offering practical messages about how to resist the temptation of beautiful women, how to prevent jealousies in polygynous households, how to discern whether a boyfriend or girlfriend will be a faithful spouse in the long run, and why withholding sex within marriage might be risky for both partners. These messages have mattered. In congregations where AIDS and sexual mortality are discussed regularly, unmarried people are more likely to report being abstinent and married individuals faithful to their spouses.
At first, we worried that reporting bias (people wanting to appear good and consistent to interviewers asking invasive questions about religion, sexual behavior, etc.) could be driving this pattern. But when tested the responses against both more subjective and more objective criteria, the story checked out: Members of these congregations are less worried about AIDS (a good indicator that they aren’t exposing themselves to much risk), and they’re less likely to test positive for HIV. Far from pushing fire-and-brimstone doctrine, religious messages about abstinence and faithfulness have been pragmatic and effective. They have reduced the spread of HIV in countless African communities that have been unreached by resources from the Global Fund and its counterparts.