Transforming
approaches to HIV
prevention in Nigeria
Nigeria
A CASE STUDY
Introduction
July 2008
marginalised groups more vulnerable to
infection.
HIV prevention is the most challenging and contentious area for
faith-based responses to HIV. Many faith-based organisations (FBOs)
promote comprehensive prevention approaches believing it is their
duty to protect life. However, other FBOs find it difficult to discuss sex
and safer practices, particularly condom use, in a faith context. This
case study describes a process which enabled FBOs in Nigeria to adopt
comprehensive approaches to HIV prevention.
Christian churches already play a
significant role in the global response
to HIV, especially in providing care and
support. The unique reach of the Christian
church, and the ability of faith leaders to
disseminate information and influence
attitudes and behaviours, mean that
the church has the potential to play a
key role in HIV prevention. To fulfil this
potential, it is vital that Christian leaders
and communities have the opportunity
to understand and address attitudes and
practices, particularly around gender and
sexual behaviour. It is important to break
the silence around HIV, dispel myths and
misinformation, and to overcome stigma
and discrimination within the faith context.
Transforming
approaches
Young people need a supportive and protective environment as well as full and accurate
information on HIV.
The spread of HIV increasingly highlights
the need for FBOs to engage with these
issues and their faith beliefs, to find a
relevant and effective response to the
complex realities of the pandemic. For
example, in many countries faithful
wives are one of the groups most at risk
of HIV infection. Prevention approaches
need not only to address personal
behaviour, but also tackle the causes and
effects of poverty, which put people at
risk of HIV. They need to challenge the
social, cultural, political and economic
structures that make women, youth and
Tearfund and some of its partner
organisations in Nigeria were concerned
that the scope of HIV prevention work
by FBOs was confined to promoting
abstinence and fidelity. These are key
messages, but need to be incorporated
within a much more comprehensive
prevention framework (see box, page 2).
This case study describes the process
undertaken by Tearfund’s FBO partners in
Nigeria to address this, through reflecting
on their faith and cultural beliefs alongside
public health principles on HIV prevention.
This process led to a deeper understanding
of why people in their communities are
vulnerable to HIV and how churches and
Transforming approaches to HIV prevention in Nigeria
A comprehensive prevention framework
A comprehensive prevention framework involves the
promotion of safer practices, including the ABC approach
(Abstain, Be mutually faithful, use Condoms consistently and
correctly). But it also needs to encompass other evidenceinformed approaches to prevention, such as ensuring access
to testing and treatment, prevention of parent-to-child
transmission (PPTCT), universal medical precautions, and so
on. This comprehensive approach is summarised in the term
SAVE, which is promoted by INERELA+, the international
network of religious leaders living with or personally affected
by HIV. These targeted interventions have to be promoted
alongside broader factors for enabling HIV prevention, such as
challenging the low status of women and overcoming genderbased violence.
During the workshops, the diagram below (an adaption of
the CAFOD model) provided a useful tool for describing and
developing understanding of how the different components
of a comprehensive response work together and how various
frameworks, such as ABC and SAVE, fit into the wider picture.
Comprehensive HIV prevention programme design
Care and
support
Immediate
risk
reduction
ABC 1
Tackling
underlying
factors
ABC 2
Impacts
Effects
Consequences
Mitigating the impact
S
A
V
E3
HIV
Reducing risks
Decreasing vulnerability
RISKS: ROUTES OF INFECTION
INDIVIDUALS’ VULNERABILITY
SOCIETAL VULNERABILITY
1
A = Abstain
B = Be mutually faithful
C = Use Condoms consistently and correctly
2
A = Advocate for universal access to prevention
B = Break the silence
C = Challenge discrimination
3
S = Safer practices, including abstinence, delayed first sex, mutual faithfulness,
correct and consistent use of condoms, reduction in number of sexual
partners, prevention of parent-to-child transmission (PPTCT), safe blood
supply, sterile needles and syringes for IDU, universal medical precautions,
safer methods for scarification and circumcision, post-exposure
prophylaxis.
A = Access and Availability of treatment, including medication for HIV and
related infections, nutrition, information, a supportive environment with
reduced stigma and discrimination.
V = Voluntary and confidential counselling and testing.
E = Empowerment through education, in knowledge and skills, especially for
women and girls. Addressing underlying causes of vulnerability to HIV.
2
‘I now see HIV as
everyone’s problem and
that I have a responsibility.
Failure to act would be a
disaster for my ministry.’
Transforming approaches to HIV prevention in Nigeria
Church leader
Christian organisations can help protect
and support them by providing correct
and comprehensive information on HIV
prevention. The scope of the partners’
HIV prevention work has broadened to
include promoting safer practices for risk
reduction, as well as tackling underlying
factors, such as gender inequalities and
discrimination against marginalised groups.
Initial attitudes
Research into attitudes and practices
among church leaders at the start of the
process revealed a number of issues that
needed to be addressed:
■
The three champions: Dr Daniel Gobgab, Professor Sam Kunhiyop and Dr Musa Dankyau.
■
The prevention message presented by
Christian groups promoting abstinence
and fidelity was in direct conflict with
the social norms of the young people
they targeted, who are growing up in
a cultural context in which sex before
marriage is seen as normal. A recent
survey by one of the partners clearly
showed that the sexual behaviour of
young people within church youth
groups was no different from the
behaviour of those outside the church.
■
Confusion and mixed messages were
common within the church regarding
sexual conduct. People who do not
conform to Christian standards of sexual
conduct and behaviour tended to be
stigmatised and treated harshly by the
church, yet what was advocated from
the pulpit was often ignored in reality.
Male sexual promiscuity within church
communities is relatively commonplace
and widely known, but never spoken
about openly.
There was incomplete understanding
about HIV transmission, fear of
infection, reluctance to associate with
people living with HIV, and a sense of
hopelessness about AIDS.
NO CONTROL
e.g. Policies, Norms,
Cultural practices,
Natural disasters
CAN INFLUENCE
Family, Friends,
Children, Institutions
DIRECT
CONTROL (Self)
e.g. Attitudes,
Personal decisions
Participants discussed what infuence church
leaders have on HIV prevention and how this
can be extended.
■
Attitudes within the churches tended
to reinforce stigma both about
people who use condoms and about
people living with HIV. Attitudes to
condoms were very negative, equating
condom promotion with encouraging
promiscuity. People living with HIV were
condemned as sinners.
■
Pastors in local churches commonly
required that couples were tested for
HIV infection and insisted on being told
the results prior to agreeing to marry
them. This compromises confidentiality
and re-enforces the powerful and
sometimes coercive role of pastors.
to re-examine the ‘official line’ on sexual
ethics and risk reduction. This made
FBO partners ill equipped to respond
supportively and appropriately to people
both inside and outside the church. It
was vital for Tearfund and its partners to
address these issues, given the rapid spread
of HIV in Nigeria and the potential good
that could come from developing the
FBOs’ capacities to respond positively and
proactively on HIV prevention.
The process
1 INITIAL RESEARCH
Research was carried out on the scientific,
cultural and theological justification for
a comprehensive and evidence-based
approach to HIV prevention in Nigeria.
This study investigated how to overcome
The
contribution of
church leaders living
with HIV and members
of local HIV-positive
networks made a
radical impact
There was a lack of reflection on the
cultural context and on theological
Christian perspectives and an unwillingness
3
Transforming approaches to HIV prevention in Nigeria
‘I consider myself born
again when it comes to
my attitudes towards
people living with HIV,
HIV itself and stigma.’
Senior church leader
of people living with HIV. This achieved
a significant attitudinal shift and a
commitment to provide leadership to
the process.
6 WORKSHOPS FOR LOCAL
CHURCH LEADERS
Members of a local HIV-positive network share their stories.
the resistance of some FBO partners to
engage in HIV prevention beyond teaching
on abstinence and fidelity, including the
reluctance to provide full and accurate
information about the effective use of
condoms.
2 FIRST WORKSHOP FOR
HIV PROJECT STAFF
HIV project staff in partner organisations,
including two church denominations and
a range of Christian agencies, attended
this workshop. It was facilitated by public
health specialists and theological experts
as well as representatives from ANERELA+,
the African network of religious leaders
living with or personally affected by HIV.
A facilitative approach and a variety
of teaching styles were used, which
The workshop
process helped
broaden the ‘moral’
understanding of HIV
transmission to focus on
society’s responsibility
to protect those
at risk
4
encouraged learning and generated an
energy and willingness to engage with the
process of change.
3 MENTORING SUPPORT
A respected Nigerian theologian and
two health professionals who headed
the Health Services departments of their
church denominations were recruited
as ‘champions’ to provide ongoing
mentoring support for the partners as
they implemented the learning from the
workshop.
4 SECOND WORKSHOP FOR
HIV PROJECT STAFF
Nine months after the first workshop, the
project staff were brought together for a
follow-up workshop where they presented
the actions taken, challenges faced and
lessons learned. The group identified
that they were encountering resistance
to change from their senior leaders and
from local church pastors. Subsequent
workshops therefore sought to engage
these audiences.
5 CONSULTATION FOR SENIOR
CHURCH LEADERS
This two-day consultation involved
senior church leaders from the two
large denominations. It was led by the
champions, with inputs from representatives of ANERELA+ and a local network
Twenty-five local church leaders and
their wives attended these three-day
workshops. The wives lead women’s
ministry in their churches. The champions
acted as facilitators and a representative
from ANERELA+ again made a crucial
contribution in challenging and shaping
views. One participant commented: ‘There
have been a few strange and hard ideas,
but upon reflection I am beginning to
come to terms with them.’
Continuing the work
Individual and social change takes time,
and this cycle of reflection and follow-up
action will need to be repeated as the
process scales up to involve more church
leaders and FBO staff. Monitoring and
evaluation will underpin this work to
measure how knowledge and attitude
shifts are translating into changes within
church and community life and to identify
continuing challenges.
Challenges
Some of the key challenges faced during
this process were:
■
Partners were at different stages
of readiness to engage with
comprehensive HIV prevention work.
Some remain reluctant to change
positions, including on condom
distribution. Future interventions to
scale up the process will work with
groups separately according to their
levels of engagement and their different
church cultures, while continuing
to encourage exchange of learning
between partners.
Transforming approaches to HIV prevention in Nigeria
Elements of two-day workshops for church leaders
■
Participants at the first workshop did not
feel able to engage the leaders within
their organisations. It is important when
selecting participants to consider their
position of influence and what support
they need.
■
The second workshop was designed to
build on the learning of the first, so the
introduction of some new participants
at the second workshop was potentially
disruptive. The process for the first day
was swiftly redesigned to take the new
participants through a ‘crash course’
on the more controversial topics. This
ensured that the progress with the initial
group stayed on track.
1 Devotions: reflections on a relevant scripture passage
2 Welcome: introductions, expectations and setting ground rules
3 Keynote address from senior church leader experienced in HIV responses:
■
On faith and cultural understandings of causes and cures of disease.
■
On use of power: whether to accumulate it or share it; how to empower others.
■
On the ability of leaders to become facilitators of church and community
transformation.
4 Presentation of model for comprehensive prevention (see page 2)
Discuss the challenge of dealing with the whole tree – roots and branches.
5 Group work: reflect on the immediate and underlying causes of HIV
Participants list these on cards and then place each issue on one of three circles:
Where church leaders have: a) direct control; b) can influence; c) have no control.
After discussion, can some cards be shifted into areas of greater control?
6 Presentation and discussion on the Theology of Change:
■
Discuss the need for revisiting church understanding of and response to HIV.
■
Testimonies by people living with HIV shared in small groups.
■
Reflections on the group’s paradigm shift in understanding HIV prevention, written
on flip chart posters.
7 Group work presented through posters displayed in a ‘gallery walk’
Feedback, reflection and clarification of the paradigm shift in HIV responses.
8 Presentation by representative from ANERELA+
■
Discussing worldviews: Why do we think what we think? What are traditional and
cultural influences on our worldviews? e.g. Do people think HIV is a result of a curse?
What is our understanding of HIV from the perspective of faith and of public health?
■
Personal testimony of a church leader living with HIV – how stigma is experienced
and how it can be transformed.
Impact on
participants
Although it is too early to measure the
long-term impact of this process on HIV
prevention, the impact on participants can
be seen in changes of attitude around key
issues. After the workshops participants
reported:
■
Deeper insight into theological and
cultural perspectives regarding gender
inequalities and the causes and cures of
disease.
■
Attitudinal shifts transforming
the ‘moral’ understanding of HIV
infection to focus on wider communal
responsibility to protect those at risk.
9 Discussion on the purpose of the church in the context of HIV:
■
The church demonstrating the Kingdom of God.
■
The church listening to God’s people and responding to their needs.
10 Public health perspectives on HIV transmission
■
Discussing immediate and underlying causes of HIV infection.
■
Analysing deeper issues which make people vulnerable to HIV infection, such as
poverty, gender inequality, concepts of masculinity, stigma and discrimination, etc.
■
Drawing a diagram of the influences on individual behaviour: e.g. in a young man.
His picture is drawn in the centre. Around him are the various influences in his life,
such as church, family, peers, drinking bars, video shops, etc. For each area consider:
What are the expectations of others on him? How is he expected to behave? Which
area is likely to have most influence on his behaviour? What pressure does this put
him under?
11 Conclusion: Key learning points and commitments to action
The groups envision:
■
What will the church response to HIV look like in five years’ time at national,
regional and local levels?
■
What steps need to be taken?
■
What needs to be stopped and what begun?
■
What other issues do the churches need to address?
■
Personal commitments: What will I do following this workshop?
12 Ending: Evaluation. Closure in prayer
Changing attitudes
• One FBO ran its own workshop for 31
church leaders and HIV project staff
and published a communiqué which
called for ‘organisations working on HIV
to disseminate accurate, factual, and
scientific information on condoms’.
• Senior church leaders of the two
denominations endorsed the SAVE
approach to comprehensive prevention.
Denominational HIV policy documents
now tackle prevention and stigma
issues. One of the General Secretaries,
speaking at a pastors’ workshop,
described himself as ‘born again when it
comes to my attitudes towards people
living with HIV, HIV itself and stigma’.
5
Transforming approaches to HIV prevention in Nigeria
‘I have learnt broader
issues in dealing with
HIV, for example, about
SAVE versus ABC. I have
learnt the importance
of including more
comprehensive issues in
church strategies on HIV.’
Church leader
can positively contribute to church and
community life.
on prevention approaches it was necessary
to first address traditional and cultural
perspectives before tackling directly the
specific issues of HIV prevention. It is risky
to assume that attitudes and behaviour will
be easy to change simply by reiterating a
Christian worldview, without also reviewing
cultural and traditional ways of thinking.
Catalytic role played
by champions
Working with concepts
of morality
The three Nigerian champions provided
their expertise in theology and public
health as well as local knowledge. This
enabled them to recognise the nature of
underlying issues and provide immediate
insights into cultural perspectives,
facilitating the process significantly.
Through the workshops and mentoring,
the champions worked to extend the
scope of partners’ HIV prevention work.
One of the challenges in the Nigeria
process has been to be to enable
participants to develop empathy and work
positively and non-judgementally with
people displaying high-risk life styles.
Faith groups often see HIV infection as a
failure in personal morality, a view which
then creates stigma. The workshop process
helped shift attitudes to focus instead
on the ‘moral’ understanding of HIV
transmission in its deeper causes, and on
society's responsibility to protect those at
risk. This raises the question of whether it
can be ‘moral’ not to protect the lives of
those who are vulnerable to HIV through
the action of others, or who are powerless
in the face of economic pressures or
gender norms, or who have developed
addictions and risk behaviours which put
The empowerment of women and girls is key to comprehensive HIV prevention approaches.
■
Understanding of the different levels of
comprehensive HIV prevention, including
targeted risk reduction interventions,
as well as tackling underlying causes of
vulnerability.
■
Understanding of the need for appropriate
education on condoms. The participants
agreed to condoms being discussed
amongst other prevention measures in a
church setting, but felt that distribution
should be limited to the context of
pastoral counselling.
■
Local church leaders reported an understanding of the need to provide accurate
education about HIV in churches, to
maintain confidentiality around VCT and to
support people living with HIV. They were
now aware that ending stigma saves lives,
and that churches have contributed to the
problem but can be part of the solution.
Key learning
Active involvement of people living
with HIV transforms attitudes
The contribution of church leaders from
ANERELA+ and members of local HIVpositive networks had a radical impact on the
participants. These resource people helped
to highlight and challenge HIV stigma in the
church, to demonstrate the realities of life
for people living with HIV and how they can
be supported, and also to show how they
6
Addressing cultural and
traditional perspectives first
Central to the process was an exploration
of prevailing worldviews held by
participants. The relationship between
traditional cultural perspectives and
Christian theological positions was
explored in considering understandings
of the causes and cures of disease, of
sin and evil, and of gender issues. To
overcome reluctance to change positions
‘I have learnt how deep
stigma can go to destroy
a person living with HIV.’
Church leader
Churches
have a long
history of serving
the poor and
marginalised
them directly in harm’s way. Some facts of
HIV transmission, such as the risk faced by
faithful wives, challenge traditional church
teachings on faithfulness. They require
that churches also tackle issues of female
empowerment and dominant cultural
norms on male sexual behaviour.
Conclusion
Effective HIV prevention approaches
enable FBOs, government and other
service providers to contribute according to
their respective and distinctive strengths,
complementing rather than undermining
each other. These approaches must be
rooted in understanding and common
ground, which is developed through
dialogue.
Dialogue is needed amongst faith leaders
and between theologians and public health
practitioners; between FBOs and other
service providers; between church leaders,
their congregations and local communities;
between women and men, parents and
their children. Dialogue involves listening
to the other with sensitive respect for
values and beliefs, but also allows room
for challenging myths, misconceptions,
practices and attitudes that stigmatise
and increase vulnerability.
The HIV pandemic has presented
unprecedented social and ethical
challenges for churches. Churches
have a long history of serving the poor
and marginalised and have already
responded with compassion and
solidarity in providing care and support
in communities affected by HIV. A
strengthened Christian response to HIV
prevention, which informs and protects
those vulnerable to HIV while tackling the
distortions and injustices that cause such
vulnerability, would see churches and
other FBOs engage even more profoundly
with their mission in the world.
Tearfund is a Christian relief and
development agency building a
global network of local churches
to help eradicate poverty.
‘HIV is not just a personal
issue but a public issue; it
is also my issue.’
Church leader
Author and lead consultant:
Dr David MA Evans
Valuing life
Christian teaching upholds abstinence
before marriage and faithfulness
within marriage as the ideal for sexual
relationships. Tearfund upholds
Christian values. It also recognises the
reality that we are working in a world
where poverty is widespread, gender
relations are unequal, human rights are
often ignored, and abuse is common.
It is therefore not enough to talk only
about abstinence and faithfulness.
Someone may be raped. Their partner
may be unfaithful. Poverty means that
some people have no means of survival
except through sex work. Gender
inequalities mean that many women
have little control over sexual decisions.
In much of the world, abstinence and
monogamy are not the cultural norm;
HIV continues to spread.
Transforming
approaches to HIV
prevention in Nigeria
www.david-evans-consultancy.co.uk
The extent of the pandemic forces faith
communities to engage with more
complete and wide-ranging approaches
to preventing the spread of HIV. Such
approaches include preventing motherto-child transmission, promotion of
condom use, provision of antiretroviral
drugs, voluntary counselling and testing
services and clean needles and syringes.
These comprehensive approaches also
require faith communities to address
the underlying drivers of HIV, including
empowering women, promoting
positive models of masculinity,
challenging sexual exploitation and
abuse and tackling the roots of stigma
and discrimination. These approaches
will save lives and show God’s love
and care for all people in an unjust and
broken world.
Photos:
Dr David MA Evans pages 3, 4
Caroline Irby, Tearfund pages 6, 7, 8
Other photos: Tearfund
Tearfund contact: Veena O’Sullivan
Email:
veena.o’sullivan@tearfund.org
Website:
www.tearfund.org/hiv/response
Design: www.wingfinger.co.uk
© Tearfund July 2008
Adapted from Footsteps 69: Sexual health, Tearfund (December 2006) www.tearfund.org/tilz
7
www.tearfund.org
100 Church Road, Teddington, TW11 8QE, United Kingdom
Tel: +44 (0)20 8977 9144
Registered Charity No. 265464
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