SYNOPSIS Latin America and Caribbean Regional Office AIDSCAP/Family Health International 2101 Wilson Blvd., Suite 700 Arlington, VA 22201 Tel: (703) 516-9779 Fax: (703) 516-0839
Project 936-5972.31-4692046 Contract HRN-5972-C-00-4001-00 The AIDS Control and Prevention (AIDSCAP) Project, implemented by Family Health International, is funded by the United States Agency for International Development.
HIV/AIDS Prevention and Control Series
M. Ricardo Calderón Latin America and Caribbean Regional Office AIDSCAP/Family Health International
Family Health International (FHI) is a non-governmental organization that works to improve reproductive health around the world, with an emphasis on developing nations. Since 1991, FHI has implemented the AIDS Control and Prevention (AIDSCAP) Project, which is funded by the United States Agency for International Development (USAID). FHI/AIDSCAP has conducted HIV/AIDS prevention programs in 40 countries, and the Latin America and Caribbean Regional Office (LACRO) has implemented interventions in 14 countries within the region.
November 1997 For further information, contact: Latin America and Caribbean Regional Office AIDSCAP/Family Health International 2101 Wilson Blvd, Suite 700 Arlington,VA 22201 Telephone: (703) 516-9779 Fax: (703) 516-0839 Graphic Designer: Deborah Clark
The HIV/AIDS Prevention and Control SYNOPSIS Series
RELIGIOUS-BASED I N I T I AT I V E S Series Editor: M. Ricardo Calderón AIDSCAP/Family Health International Arlington,VA, USA
Prepared by: Magdalena Martínez Anna Dulaney MAP International–Latin America Quito, Ecuador
Project Coordinator: Mary L. Markowicz AIDSCAP/Family Health International Arlington,VA, USA
Published by the Latin America and Caribbean Regional Office of The AIDS Control and Prevention (AIDSCAP) Project Family Health International
The opinions expressed herein are those of the writer(s) and do not necessarily reflect the views of USAID or Family Health International. Excerpts from this booklet may be freely reproduced, acknowledging FHI/AIDSCAP as the source.
Social and Religious Context of HIV/AIDS in Latin America Overview of HIV/AIDS in Latin America Social Context: Gender, Policy, Political and Economic Issues Religious Context of the Region
5 5 6 11
Mainstreaming RBIs: Benefits at Low Cost HIV/AIDS and the Church’s Mandate HIV/AIDS Challenges the Church
17 17 25
Models of RBIs in Latin America NGO Programs: Local Capacity Building Church Congregation or Parish Programs: Participatory Approaches Network-based Programs: Collaborative Action Hospital-based Programs: Care and Management International Programs: Coalition Building Achievements of RBIs in Latin America
31 31 32 33 34 35 37
TABLE OF CONTENTS
TABLE OF CONTENTS
acquired immune deficiency syndrome
AIDS Control and Prevention Project
Family Health International
human immunodeficiency virus
Latin America and the Caribbean
Latin America and Caribbean Regional Office
MAP International–East and Southern Africa
MAP International–Latin America
Ministry of Health
National AIDS Control Program
Pan American Health Organization
private voluntary organization
sexually transmitted infection
United States Agency for International Development
World Health Organization
We would like to acknowledge and recognize the contributions, work and efforts of the Implementing Agencies — NGOs, PVOs, CBOs, NACPs/MOH, Social Security Institutes, and private sector enterprises — with whom LACRO has worked and for all that we have learned and accomplished together in HIV/AIDS prevention and control. We are especially grateful to Magdalena Martínez and Anna Dulaney of MAP International-Latin America for writing this booklet. They, in turn, would like to express their gratitude to the following MAP International personnel for their editorial and research assistance: Lic. Mauricio Solis, Latin American Regional Director; Ms. Ndunge Kiiti,Associate on study leave from MAP East and Southern Africa; John Butin, Director of Program Planning and Coordination; and Susan Reeves, Director of Grants Funding. MAP International is a non-profit relief and development organization that promotes the total health of people living in the world’s poorest communities. MAP (Medical Assistance Programs) works alongside others in community health development, disease prevention and eradication, relief and rehabilitation, and global health advocacy. For further information, contact: MAP International, 2200 Glynco Parkway, P.O. Box 215000, Brunswick, GA 31521-5000 Telephone: (912) 265-6010. We take this opportunity to also thank all the staff members of AIDSCAP/LACRO, including former staff members, for their overall support and assistance to LACRO activities: Joseph Amon, Lee Arnette, Mimi Binns, Oly Bracho, Marianne Burkhart, Rebecca Coleman, Mark Chorna, Genie Liska, Cathy Mamedes, Mary L. Markowicz, Robert Martínez, Mary Kay McGeown, Steve Mobley, Manuel Mongalo, Polly Mott, Sara Padilla, Marvelín Parsons,Amparo Pinzón, Luis Rodríguez, Melissa Rosenberger, Diana Santos, Isabel Stout, Molly Strachan, and Oscar Viganó. In addition, we express our appreciation to the AIDSCAP LAC Resident Advisors: Catherine Brokenshire, Jamaica; Martha Butler Acknowledgements
de Lister, Dominican Republic; Eddy Genece, Haiti; Gale Hall, Jamaica; Jorge Higuero Crespo, Honduras; and Maria Eugenia Lemos Fernandes, Brazil; and other AIDSCAP staff for their insights and contributions.We are grateful to Peter Lamptey, FHI Senior Vice President of AIDS Programs and Project Director of AIDSCAP, and Tony Schwarzwalder, Deputy Project Director of AIDSCAP, for their continued support of LACRO activities. Finally, we wish to extend our gratitude and appreciation to the USAID Global Bureau’s HIV/AIDS Division, field Missions in Latin America and the Caribbean, and to the Population, Health and Nutrition Team in the Office of Regional Sustainable Development of the USAID LAC Bureau, particularly James B. Sitrick, Jr., for the support and funding of the Information Dissemination Initiative and other LACRO programs.
The HIV/AIDS Prevention and Control Series, SYNOPSIS, is a summary of the lessons learned by the Latin America and Caribbean Regional Office (LACRO) of the AIDS Control and Prevention (AIDSCAP) Project. AIDSCAP is implemented by Family Health International (FHI) and funded by the United States Agency for International Development (USAID). The series is a program activity of the LACRO Information Dissemination Initiative and was created with several goals in mind: to highlight the lessons learned regarding program design, implementation, management and evaluation based on five years of HIV/AIDS prevention and control experience in LAC countries to serve as a brief theoretical and practical reference regarding prevention interventions for HIV/AIDS and other sexually transmitted infections (STIs) for program managers, government officials and community leaders, non-governmental organizations (NGOs), private voluntary organizations (PVOs), policy and decision makers, opinion leaders, and members of the donor community to provide expert information and guidance regarding current technical strategies and best practices, including a discussion of other critical issues surrounding HIV/AIDS/STI programming to share lessons learned within the region for adaptation or replication in other countries or regions to advance new technical strategies that must be taken into consideration in order to design and implement more effective prevention and control interventions to advocate a holistic and multidimensional approach to HIV/AIDS prevention and control as the only way to effectively stem the tide and impact of the pandemic
AIDSCAP (1991-1997) was originally designed to apply the lessons learned from previous successful small-scale prevention projects (1987-1991) to develop comprehensive programs to reduce the sexual transmission of HIV, the primary mode of transmission of the virus.AIDSCAP applied three primary strategies — Behavior Change Communication, STD Prevention and Control, and Condom Programming — along with supporting strategies of Behavioral Research, Policy Development and Evaluation. The success of this approach, based on the combination of strategies and targeted interventions, has been widely documented. The AIDSCAP Project, in fact, has been recognized as among the best and most powerful international HIV/AIDS prevention programs to date.1 AIDSCAP has worked with over 500 NGOs, government agencies, community groups and universities in more than 40 countries; trained more than 180,000 people; produced and disseminated some 5.8 million printed materials, videos, dramas, television and radio programs, and advertisements; reached almost 19 million people; and distributed more than 254 million condoms.2 However, the pandemic continues to escalate at a rate that outpaces our successes. Thus, we need to build upon these successes, learn from our experiences, and determine what has worked and what is missing in order to respond with added effect in the future.The magnitude and severity of the HIV/AIDS pandemic calls for boldness, flexibility, wisdom and openness. The world cannot afford to continue to fight HIV/AIDS only with current thinking and tools. We must look toward new thinking and strategies that complement and carry the current state-of-the-art approaches forward in the fight against HIV infection. Therefore, LACRO endorses, promotes and elevates Gender Sensitive Initiatives (GSIs), Civil-Military Collaboration (CMC), Religious-Based Initiatives (RBIs), and Care & Management (C&M) as the new prototype of technical strategies that must be incorporated on par with the strategies that have been implemented to date. Walls, barriers and biases have to come down in vi
order to unlock the strengths, benefits, potential, synergy and/or resources of GSIs, CMC, RBIs and C&M. More importantly, approaches that compartmentalize strategies can no longer be justified. Despite the efforts to integrate and coordinate amongst and between technical strategies and different sectors of society, prevention programming is barely scratching the surface of what a real comprehensive effort should be. One of the most important lessons learned about HIV/AIDS is that it is not only a medical problem, nor is it exclusively a public health problem. Rather, the pandemic is in addition a socioeconomic problem and, as such, threatens both the sustainable development of developing countries and challenges the ethical foundations of the developed world. HIV/AIDS has become a challenge to health, development and humanity. For lasting success, a genuine multidimensional approach is urgently needed. One that demands new forms of wealth distribution, educational opportunities and development; attempts to resolve the inequalities in gender and power; acknowledges the individual, environmental, structural and superstructural causes of and solutions for the pandemic; and aims to balance the disparity between the “haves” and the “have-nots,” resulting in more sustainable, equitable, effective and compassionate efforts. Therefore, the SYNOPSIS Series reaffirms that current HIV/AIDS prevention and control strategies work, and contends that new technical strategies are needed and can be effective and complementary. The Series also strongly advocates for, and will discuss in a separate issue, the Multidimensional Model (MM) for the prevention and control of the pandemic. This model must guide national, regional and international planning and programming in order to achieve measurable and significant gains that can truly effect changes at the individual, societal, environmental and structural levels. We trust the reader will be open to our futuristic thinking and will contribute to the further development of the strategies presented here as well as others. We hope the SYNOPSIS Series Prologue
will stimulate discussion and reflection, propel continued dialogue, and encourage the pioneering of new combinations of innovative approaches.
M. Ricardo Calderón, MD, MPH, FPMER. Regional Director Latin America and Caribbean Regional Office AIDSCAP/Family Health International
This SYNOPSIS booklet discusses the importance of religiousbased initiatives (RBIs) through a holographic approach. Holography is a special photographic technique that produces images of three dimensional objects. This photographic record is called a hologram, and one of its main applications is that any fragment of the hologram can regenerate the entire image, even if the fragment is extremely small. In other words, if a negative from an ordinary picture is cut into two, the print from each half would only show half of the picture. Conversely, if a holographic negative is cut in two, the print from each half would show the entire picture. If these halves are cut again, the print from any one of the pieces will reconstruct the whole picture.3, 4, 5 Utilizing the holographic model, this booklet was written such that any one of the sections (holograms) will provide the reader with an understanding of the whole subject matter. First, we describe the entire strategy or topic of discussion in one sentence, the widespread definition and/or our own definition of the subject (Hologram 1). Next, we present a one-paragraph abstract of the topic (Hologram 2), expanding upon the original definition. Then, we present the topic by providing a summary or recapitulation of the main points of each of the sections of the booklet (Hologram 3). Finally, the entire strategy is again presented by virtue of the complete text of the booklet (Hologram 4). We anticipate that the Holographic Overview of Religious-Based Initiatives will benefit both the seasoned professional and the novice. It provides a quick, general overview of RBIs as well as context and background. It also directs the reader to specific sections that may be of greatest interest or that the reader would like to review first or at a later date. Thus, we hope this approach will enable the reader to make fuller use of the booklet as a reference guide, as it provides a simple and concise definition of RBIs, a brief description of the topic, a summary of the discussion, and finally, the complete text — all in one document.
The reader should note that while we have tried to include the key issues surrounding RBIs in this SYNOPSIS, the booklet is not meant as an exhaustive discussion of all of the issues regarding the strategic role of the church in the fight against HIV/AIDS.
The Whole Strategy Hologram 1: The Definition Religious-Based Initiatives (RBIs) in HIV/AIDS prevention and care represent the efforts of religious institutions to work together with individuals, families and communities, as well as multilateral, governmental and non-governmental organizations, to transform the conditions that promote, in a sustainable way, their physical, emotional, economic, social, environmental and spiritual well-being.
The Whole Strategy Hologram 2: The Abstract Religion plays a critical role in the lives of Latin Americans. The strong influence of Church leaders in politics and society, the presence of Churches in most communities, and the approximate 88 percent of Latin Americans who identify themselves as Catholics (75 percent) or Protestants (13.7 percent) make religious-based initiatives a uniquely effective and needed partner to combat HIV/AIDS. RBIs fill a strategic niche in the struggle against HIV/AIDS globally. When properly supported and coordinated, they can be some of the most strategic prevention and control vehicles through which to slow the spread of the pandemic. Some sectors of the Church will undoubtedly continue to be challenged to overcome their prejudice against people with HIV/AIDS. However, the magnitude and severity of the pandemic is pressuring both religious and secular institutions to modify their ways of responding to HIV/AIDS; to effect changes within their structures, beliefs and practices; and to find their commonalities and complementarities. The involvement of the Church in HIV/AIDS prevention and care is critical not only for x
society but for the Church as well. The Church has the infrastructure, means and mandate to combat HIV/AIDS, yet much of its vast potential and resources remain untapped to date. Multilateral, governmental and non-governmental organizations working in HIV/AIDS must escalate to a new level of partnership and collaboration for enhanced effectiveness and wider impact. Moreover, failure to mobilize and utilize this foundational institution of Latin American society would almost surely mean failure in the struggle to promote truly effective prevention and control efforts within the region.
The Whole Strategy Hologram 3: The Summary Social and Religious Context of HIV/AIDS in Latin America HIV/AIDS is spreading consistently and rapidly in all countries in Latin America. It does not discriminate by sex, age, occupation, religion, geography or economics. Although only 13 percent of the number of people currently living with HIV/AIDS worldwide are found in Latin America, the fact that this number is growing by 25 percent each year is of grave concern.The increasing incidence of transmission among the general population demands that everyone become involved in responding to HIV/AIDS. However, the social context of HIV/AIDS in the region is complicated by gender, policy, political and economic issues. Cultural, biological, religious and economic factors strongly impact the vulnerability of women to HIV/AIDS within the region. Open discussion towards just and rational policymaking around HIV/AIDS has been difficult. Scarce resources for prevention and care have been the rule rather than the exception. As more members of the Church are living with HIV/AIDS, the Church is increasingly being challenged and motivated to develop prevention and care strategies and to include these individuals in the life of their congregations. Rather than condemning others, the Church is studying how HIV/AIDS can be a “chance to express the grace of God.”
Mainstreaming RBIs: Benefits at a Low Cost RBIs are pivotal to the success of prevention and care efforts in Latin America as well as globally. Churches are found in nearly all communities in the region and wield a significant level of cultural, political, social, educational and economic influence. The Church can be viewed as the largest, most stable and most extensively dispersed non-governmental organization in any country. Churches are respected within communities and most have existing resources, structures and systems upon which to build.They possess the human, physical, technical and financial resources needed to support and implement small and largescale initiatives. They can undertake these actions in a very cost-effective manner, due to their ability to leverage volunteer and other resources with minimal effort. Unfortunately, the resources, capabilities and potential of the Church are considerably neglected or untapped, and it has not been considered part of the solution and/or a driving force in the fight against HIV/AIDS. Religious leaders and institutions have a powerful voice in society, encourage greater focus on belief and value change efforts, promote policymaking that includes the whole “family unit,” and foster and provide access to care for those affected by HIV/AIDS. On the other hand, the Church is challenged by HIV/AIDS. In order to maximize the Church’s potential contribution, both the Church and those organizations partnering with it must overcome two main challenges — the need for institutional and structural change within the Church and the need for “limited domain collaboration” concerning prevention and control strategies adopted by RBIs. Models of RBIs in Latin America Current religious-based interventions taking place in Latin America are generally not well known. However, they are having a profound impact on HIV/AIDS programming within the region. A sample of the different types of models and efforts presently underway in Latin America can be categorized as follows: a) local capacity building through NGO programs in Chile,Venezuela and Ecuador; b) participatory approaches through church congregation or parish programs in Argentina, Colombia, Ecuador and Honduras; c) collaborative actions xii
through network-based programs in Ecuador, Panama, Guatemala and the Dominican Republic; d) care and management through hospital-based programs in Ecuador, Honduras and Brazil; and e) coalition building through international programs, such as the work of MAP International in Latin America and Africa, and WHO/PAHO in Central America. Achievements of RBIs in Latin America Foremost among the achievements of RBIs has been the Church’s ability to encourage voluntarism and to leverage resources in the fight against HIV/AIDS. Many Christian NGOs, churches and parishes, as well as Christian networks and/or Christian hospitals, have stepped forward to combat the pandemic and to give hope to those who are affected by it. Church pastors, priests and congregations are increasingly changing their attitudes towards people living with HIV/AIDS. Local congregations have participated in marches, all-night vigils, health campaigns and World AIDS Day celebrations. The Church is filling a gap that exists for people living with HIV/AIDS —that of responding to their spiritual needs and questions about suffering and death. In the absence of the most advanced treatments in the developing world,AIDS remains a death sentence and, thus, the greater need for emotional and spiritual support. Local churches may be the only place where people receive understanding, compassion and answers to their complex questions and situations. HIV/AIDS has led Catholic, Evangelical and Episcopal churches to work together and commit to concrete interdenominational actions. Collaboration between health professionals and people from the religious sector advocates for a holistic approach to address the variety of needs of people living with HIV/AIDS, primarily the integration of spiritual and emotional health needs with the bio-medical ones. Regional efforts coordinated by international agencies or development organizations allow for the exchange of experiences and lessons learned.
Lessons Learned A certain degree of mutual distrust remains between the Church and many multilateral, governmental and non-governmental organizations in Latin America, despite their many shared goals in the struggle against HIV/AIDS. However, RBIs can have a powerful impact on public policy and need to be mobilized as an important part of any HIV/AIDS effort. RBIs in the region have shown the effectiveness of using different communication strategies to reach different population segments. Training materials that respect denominational and church context differences and that focus on topics of sexuality, counseling and pastoral support are proving effective in fighting HIV/AIDS. Positive changes in attitudes and perspectives have occurred in churches and other affiliated groups working on health issues in the region, but conceptual barriers to collaboration in HIV/AIDS work still exist. RBIs already working in HIV/AIDS can play a key educational role in facilitating further growth and openness within these Churches and institutions. Difficult ethical issues raised by certain strategies, such as the promotion of condom use, can be resolved sufficiently to allow collaboration and compromise, if addressed openly and with mutual respect. Agreeing to limit the range of cooperation to the issue at hand and to set aside other areas of disagreement can perhaps defuse some of the tensions inherent in collaboration among diverse groups and foster cooperation. Genuine debate and action concerning how the Church in Latin America can best show solidarity with those living with HIV/AIDS and their families is sorely needed. The strengths and achievements of RBIs to date — interdenominational action, high rate of voluntarism, changes in church and health personnel towards a more holistic attitude and so forth — can be the building blocks for future coordination between the Church and multilateral, governmental and other non-governmental efforts in Latin America. In brief, the fundamental point regarding HIV/AIDS is that the response of Christian communities to the pandemic should above all be based on compassion and a commitment to serve others.
Recommendations The Church and multilateral, governmental and non-governmental organizations have a great deal to offer each other by partnering in the struggle against HIV/AIDS through religious-based initiatives. The Church can gain new tools, perspectives and partners with which to pursue its responsibility towards the community, and multilateral and other non-religious efforts can gain an effective ally in the Church — an institution with vast reach, resources and potential for impacting prevention and care in the region. Recommendations for future HIV/AIDS prevention and care programming and partnering include: a) an open dialogue and compromise to replace any lingering mistrust and separation between religious-based and non-religious international, national and local efforts; b) the participation of RBIs in the development of HIV/AIDS related legislation and policies, particularly as they focus on justice and dignity; c) greater resources allocated for the production and distribution of educational and training materials specifically designed for use by Churches; d) development of partnerships between religious and secular institutions based on mutual respect, flexibility, and the commitment to cooperate towards limited, mutuallyagreeable goals; e) pursuit of enhanced coordination and networking within the Church and across lines of denomination; and f) increased allocation of resources and support to those RBIs committed to the compassionate care of individuals living with HIV/AIDS and their families.
Hologram 4: The Detailed Description
INTRODUCTION This booklet, a collaborative production of AIDSCAP/LACRO and MAP International, is written with two primary purposes. First, it attempts to increase awareness within the international health community of the strategic niche that religious-based initiatives (RBIs) are fillReligious-based initiatives, ing in the struggle against HIV/AIDS globally, with particular emphasis on when properly supported and Latin America. Secondly, it urges the Church and multilateral, governmental coordinated, can be some of and non-governmental organizations working in HIV/AIDS prevention and the most strategic vehicles care to move to a new level of partnership and collaboration for enhanced through which to slow the effectiveness and wider impact. spread of HIV/AIDS. Moreover, failure to mobilize and utilize this foundational institution of Latin American society would almost surely mean failure in the struggle to promote truly effective and penetrating prevention efforts in the region.
The booklet draws from the experience of both AIDSCAP and the Latin American Office of MAP International, based in Quito, Ecuador. One focus of MAP International’s work in Latin America is to encourage and support the Church to be more involved in total health issues, including responding to the HIV/AIDS pandemic. MAP International’s collaborative work throughout Latin America in mobilizing churches and other religious institutions for total health development has demonstrated that RBIs have a key role to play in an integrated strategy to combat HIV/AIDS in the region.
The Whole Strategy
Religious-based initiatives, when properly supported and coordinated, can be some of the most strategic vehicles through which to slow the spread of HIV/AIDS. Particularly in Latin America, the almost 88 percent Christian population, the presence of Churches in most communities, and the strong influence of Church leaders in politics “Total health” is “the capacity and society, make RBIs a uniquely effective partner to combat this pandemic. of individuals, families and Moreover, failure to mobilize and utilize this foundational institution of Latin communities to work together American society would almost surely mean failure in the struggle to promote to transform the conditions that truly effective and penetrating prevention efforts in the region. promote, in a sustainable way, The involvement of the Church in the prevention and care of HIV/AIDS is crittheir physical, emotional, ecoical not only for society, but for the Latin American Church as well. The relinomic, social, environmental gious values they espouse lead many of these initiatives to focus on prevention and spiritual well-being.” — through promoting sustained value and behavior change through modifying beliefs — as well as care — through compassionate outreach or in-house pastoral or physical health care for those affected by HIV/AIDS. This dual focus provides a unique opportunity for leveraging of resources and strengths that can complement other ongoing efforts to develop strategies in the region. As this booklet demonstrates, the Church in Latin America already has the infrastructure, means and mandate to tackle HIV/AIDS ministry effectively. Increasingly, as more RBIs in the region become active in various forms of ministry in this area, the Church will only grow in its capacity to implement distinct initiatives and also to serve as an effective partner with others in this struggle. Policy makers, program managers, donors, and community and government leaders will continue to recognize the benefits and resources to be gained from working with RBIs. 2
This booklet begins with a general review of HIV/AIDS and the social and religious context in Latin America. Next, the strengths and strategic advantages of religious-based initiatives are summarized, followed by an analysis of RBI models active in the region as well as highlights of their achievements. Finally, major lessons learned are presented along with practical recommendations encouraging collaboration between the Church and other organizations working in HIV/AIDS prevention and care. For the purposes of this booklet, the term “Latin America” refers to the following countries: Argentina, Belize, Brazil, Bolivia, Colombia, Costa Rica, Chile, the Dominican Republic, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Puerto Rico, Uruguay and Venezuela. To date, the most well-known religious-based initiatives working in HIV/AIDS prevention and care in Latin America have been coordinated by either Catholic or Protestant groups. Therefore, the use of the term “religious-based initiatives” refers to the work of these groups, and “the Church” refers specifically to the Catholic or Protestant churches, unless otherwise stated. Finally, as MAP International defines it,“total health” is “the capacity of individuals, families and communities to work together to transform the conditions that promote, in a sustainable way, their physical, emotional, economic, social, environmental and spiritual well-being.”
Overview of HIV/AIDS in Latin America In a progression now well-documented, the world was surprised by an emerging new health risk during the late 1970s and early 1980s — HIV/AIDS. At first, attempts to address the epidemic in the larger community and mainstream societal levels were hampered by the sense that HIV/AIDS in the Western World first affected groups known for their “anti-social” or risky conduct — sex-workers, homosexuals and drug users — persons whom the general society preferred to ignore. As predicted, however, HIV/AIDS has since passed into the general population. It does not discriminate by sex, age, religion, geography or economics. As we approach the end of the twentieth century, HIV/AIDS holds a place in public health efforts like no other pandemic in recent decades. While the search for a cure continues, the past two decades have witnessed a disproportionate impact of this pandemic in the poorest regions of the world — Africa,Asia and Latin America. According to the World Health Organization’s Regional Program of AIDS/STDs June 1997 report, there are an estimated 29.4 million accumulated HIV infections worldwide. Of the 1.6 million reported AIDS cases around the globe, half of these (almost 800,000) are in the Americas.6 The differences between reported cases and estimations of accumulated infections show that there is a great deal of misdiagnosis, delayed reporting and underreporting. Of the cases in the Americas, two thirds are in North America and one third are in the South, but it is predicted that within a few years this ratio will be reversed.7 Although the number of people currently living with HIV/AIDS in Latin America may be a relatively small portion of the total global cases (around 13 percent), the fact that this number is growing by 25 percent each year is of grave concern.6 Social and Religious Context of HIV/AIDS in Latin America
SOCIAL AND RELIGIOUS CONTEXT OF HIV/AIDS IN LATIN AMERICA
SOCIAL AND RELIGIOUS CONTEXT OF HIV/AIDS IN LATIN AMERICA
There are marked differences in the incidence of HIV/AIDS among countries and sub-regions in Latin America, but it is clear that the pandemic is now spreading rapidly in all areas of the region. In 1996, Honduras had the highest ratio of cases per million inhabitants at 168.9, with Belize second at 129.6. Brazil and Mexico reported the largest number of AIDS cases in Latin America, but they represent a relatively lower rate of 95.2 and 46.0 cases per million population, respectively.8 The principal modes of transmission in the region are believed to be various forms of risky sexual contact (including prostitution and unprotected heterosexual or homosexual intercourse with multiple Throughout the region, there is partners), needle-sharing during drug use, and blood transfusions. Research increasing cognizance of the indicates that throughout the region, AIDS cases are rising most rapidly particular vulnerability of through heterosexual contact. 9 women to the HIV virus. The
Social Context: Gender, Policy, Political and Economic Issues
WHO reports that worldwide, Gender Throughout the region, there is increasing cognizance of the particular infected with HIV are now vulnerability of women to the HIV virus. The WHO reports that worldwomen and that this population wide, almost 50 percent of people infected with HIV are now women and group is the fastest growing that this population group is the fastest growing segment of the segment of the HIV/AIDS HIV/AIDS population.6 A report from a recent international conference on population.6 HIV/AIDS stated that in South America, “immediate and targeted attention to women in the general population and adolescents is now required, as these subsets become the groups most vulnerable in the current phase of the pandemic.”10 almost 50 percent of people
Cultural, biological, religious and economic factors strongly impact the vulnerability of women to HIV/AIDS in Latin America — and RBIs hold unique resources for addressing these factors: “Machismo” culture. Traditions that establish different norms and patterns of conduct for the sexes, often tacitly or overtly legitimated by various religious groups, may easily translate into inequalities for women and subjection to men. Inequality of educational opportunities, the persistence of traditional gender roles, and the dependence and lack of social power of women, all have serious consequences for the vulnerability of women to HIV/AIDS. Church groups committed to transforming the subtle religious support given to “machismo” in the region can play an important role in beginning lasting cultural change. Biology. Typically, Latin American women marry at a young age (many before the age of 17) and often to much older men. At this age, women may be physiologically more vulnerable to STIs due to the effects of hormonal changes on the genital mucosa. Transmission of STIs, including HIV, is more efficient from male to female than vice versa. A pregnant woman infected with HIV has a 25-40 percent chance of passing on the virus to her child — requiring her to confront her own death as well as the risk she has transferred to her child.11 The Church needs to recognize this innate vulnerability as worthy of special efforts to enhance protection and communal care for women. Religion. The Church and some of the traditional religions of the region have contributed in varying degrees to the cultural construction of sexual taboo myths that in practice apply more harshly to women.Within the Church, a woman is normally assumed to be a virgin when she marries, yet a man is “expected” to have some sexual experience. A young woman’s self esteem may be further damaged by church teachings emphasizing Eve as the cause of Adam’s original sin, thus “responsible” for the sin of all subsequent generations. Restrictions on the leadership role of women in Latin Social and Religious Context of HIV/AIDS in Latin America
American churches vary widely among congregations and denominations, and this too is often demeaning for women. Churches committed to promoting changes in these areas from within the institution need support and partnership. Economy. Widespread rural migration and poverty have exerted pressure on men to leave their families for long periods in search of work in the city or in other countries.This often leads to extra-marital sexual relationships, placing the man at risk of contracting STIs or HIV/AIDS. When this man returns to his home, he may then transmit the infection unknowingly to his wife. In Ecuador, for example, this is particularly true among the indigenous population living in the
Laura, like many women, did not know the sexual practices of her husband outside of their marriage relationship. Laura was not aware that she was at risk. She could not question her husband about his sexual conduct, because if she did, she exposed herself to the possibility of physical or psycho-emotional violence. Laura could not ask her husband to use a condom because this would be seen by him as an affront to his masculinity. Due to cultural norms, she was also unable to use a “female condom” as a means of protecting her life. Laura’s only “mistake” was being faithful to her husband, and although he knew he was dying, he hid the reason from her until it was too late. One year later, she was diagnosed as HIV positive. Clearly, cultural issues regarding the self-esteem of men and women and a generalized lack of regard for women in society, greatly increased Laura’s likelihood of acquiring HIV/AIDS from her husband.13
region of Cañar, where the increase in AIDS cases in the past four years is directly attributed by doctors there to the increase of migration by men to coastal cities in Ecuador or to the United States.12 Public Policy Over the years since the appearance of HIV/AIDS in Latin America, an array of government policies related to issues surrounding HIV/AIDS have been proposed to balance the competing demands of varied interest groups — medical and health care professionals, government institutions, non-governmental organizations, the mass media, public opinion and the wide diversity of church-related constituencies in the region.14 Given the variety and intensity of the challenges presented by the Latin American social context, open discussion towards just and rational policy-making around HIV/AIDS has been difficult. Attempts to create coherent public policy capable of aiding in the prevention and control of HIV/AIDS transmission have met with a number of obstacles that have often impeded the implementation of these policies, including: Loss of continuity. Frequent changes in government, leading to the replacement of “old” health programs and personnel with “new” ones with different emphases and HIV/AIDS prevention strategies, create a serious impediment. For example, the first attempt at legislating a new law related to HIV/AIDS in Honduras, debated in that country’s Congress in 1991, failed precisely due to a change in government.15 Under-funded health budgets. A precarious health budget is a problem found in many countries — only in the past few years has HIV/AIDS become part of national health agendas in most of Latin America.16 In Ecuador, for example, the health program of the current government constitutes only two percent of the overall budget, and the AIDS program is one of the last stated priorities within this health budget.17 In the Dominican Republic, PROCETS (the principal government agency of AIDS education) has a monthly budget of less Social and Religious Context of HIV/AIDS in Latin America
than $7,000 for its activities — sorely inadequate to its task. A combination of complex factors, including tremendous external debt commitments, the priority of attending to primary care health needs and the existence of corruption in government ministries, is exacerbating this problem of underfunded health budgets. Lack of human rights policies. Specific policies concerning human, labor and legal rights for individuals with HIV/AIDS do not exist in most countries, and where they are in place, they are often not enforced. In Ecuador, for example, the Ecuadorian Commission on Human Rights and AIDS (CEDHSIDA) recently relied on the support of non-governmental organizations, including MAP International, to present new laws to Congress which would ensure the implementation of existing laws in a way beneficial to those with HIV/AIDS. In the past, despite active lobbying work, others have not been successful in convincing the Ecuadorian Congress to adopt these laws.18 Political Economy An inquiry into the political economy of the pandemic in Latin America seems to tell a familiar story: scarce resources for prevention and care, with vested financial and political interests controlling much of who gets how much and why. For example, in the Dominican Republic, the government is worried about how HIV/AIDS will affect tourism, the biggest industry in the country. Dr. Martha Butler de Lister, Resident Advisor of the AIDSCAP project in the Dominican Republic, states,“It is not politically correct to mention AIDS in this country because the economy might suffer.”19 Similar economic interests determine the response of many countries to HIV/AIDS. At the microlevel, medical attention is out of reach for many living with HIV/AIDS in developing countries. In Latin America, the cost of drug treatment for AIDS averages between US $1,000 and $2,000 per month, while the average basic family salary is around $250. Even if a family can cover the cost of medicine, very little money is left to pay for food or rent.20 Moreover, the segment of the population most affected by HIV/AIDS is that which is the 10
The segment of the population most affected by HIV/AIDS is that which is the most economically productive — those between 15-45 years of age.6 When these individuals, who previously brought in a large portion of the family’s income, are forced to leave work (due to discrimination in the early stages and physical weakening in the latter stages), the entire family suffers.
most economically productive — those between 15-45 years of age.6 When these individuals, who previously brought in a large portion of the family’s income, are forced to leave work (due to discrimination in the early stages and physical weakening in the latter stages), the entire family suffers. Religious Context of the Region Religion has played a critical role in the lives of Latin Americans since the beginning of recorded history in the region. Though a variety of religions flourished before the arrival of the Spaniards in the 16th Century, from that time forward, it has been Christianity that has occupied the central religious role for the majority of Latin Americans. Catholicism was the earliest form of Christianity in the region, and with its various forms and adaptations, it has long been “The Church” to the majority of Latin Americans. Over the past few decades, other Christian denominations have experienced significant growth, in the process dramatically changing the religious dynamics of the region.
Current statistics indicate that approximately 74 percent of Latin Americans identify themselves as belonging to the Catholic Church, while a growing 13.6 percent identify themselves as Protestants or “Evangelicals.” This latter group also includes the Episcopal/Anglican Church, but in practice, this denomination is often treated as a third segment of the Christian population in many Latin American countries since it is seen as combining elements of the other two groups.The remaining 13 percent identify themselves as “other,”“non-religious,”“animist,” or “spiritualist.” In Cuba and Uruguay, those identified as “non-religious” constiSocial and Religious Context of HIV/AIDS in Latin America
tute approximately one-third of the population, but in most other countries this percentage is quite small. Brazil, Bolivia and the Dominican Republic (and to a lesser extent Guatemala, Peru and Venezuela) have a large number of people involved in spiritualist or other traditional religious practices, in many cases blending ancient tribal customs with Catholic practices. However, the majority of these individuals still officially identify themselves as belonging to the Catholic Church.21 Given the predominance of religious affiliation in the region, and the historic, cultural and communal significance of the Catholic Church throughout Latin America, religion and religious institutions appear destined to continue to play an important role in the life of most Latin Americans. This context has allowed religious leaders to develop a key voice in all aspects of the life of the community — including health issues, behavior decisions and sexual practices. This moral and communal authority has been powerfully utilized in the fight against the spread of HIV/AIDS in communities all over the world. For over a decade, the Christian Church globally has acknowledged its role in the fight against HIV/AIDS. In 1987, the World Council of Churches proclaimed: The urgency of the problem of AIDS profoundly challenges us to be the Church in deed and in truth; to be the Church as a healing community. AIDS is a heartbreaking problem, challenging churches to open their hearts and repent of their immobility and their rigid morality.22
The following year, Pope John Paul II, in an address to the Catholic Health Association, made these remarks concerning AIDS: Today you are faced with new challenges, new needs. One of these is the present crisis of immense portions which is that of AIDS . . . Besides your professional contribution and your human sensitivities towards all affected by this epidemic, you are called to show the love and compassion of Christ and His Church.23 While the world Christian movement has recognized the strategic role of the Church in HIV/AIDS, the Church in Latin America has perhaps been slow to respond. One reason for the delay may have been that until the early 1990s, the number of HIV/AIDS cases reported in the region was relatively small. Later, as the numbers began to increase, the complexity of the issues, challenges and opportunities facing the Church began to surface more openly. For instance: Lingering Protestant/Catholic tension. Protestants and Catholics in the region remain divided over significant issues. While tension between the two churches has decreased somewhat in recent years, at least two distinct “Churches” are seen to exist in Latin America. Furthermore, other divides exist within both of these broad groups. Protestants from what are often called “mainline” denominations in the U.S. (Methodist, Presbyterian,American Baptist, and so forth — largely identifying with relatively liberal theological and social positions), and Protestant “Evangelicals” (various independent denominations, Assemblies of God, many Mission agencies, and so on — identifying with more conservative positions, generally) have experienced significant polarization over certain issues in recent decades. As a result of these tensions, a unified “Church” response to the pandemic has been difficult. Rapid church growth in some sectors. The fastest growing segments of the Church in Latin America are those associated with charismatic or Pentecostal movements. These moveSocial and Religious Context of HIV/AIDS in Latin America
ments tend to focus attention on the daily problems of the congregation and God’s supernatural response to them as in, for example, God’s provision for the poor. While it appears that opportunities exist within at least some of these groups to promote openness to HIV/AIDS ministry as part of this focus on concrete struggles, the variation among these groups makes generalization difficult. Social action in tension with evangelism. Balancing the promotion of social responsibility and evangelism in the Church has proved challenging. Latin American Evangelicals are sometimes stereotyped for not taking seriously the concrete needs of people and communities, while Catholics in the region have been in turn accused of not focusing enough on evangelization — perhaps being too focused on social action. Protestants (and to a lesser extent, Catholics) themselves were sharply divided over related issues as articulated by the Liberation Theology movement beginning in the late 1960s in the region. Opposition or support for this movement became a litmus test for fidelity in some of the more conservative and liberal branches of each church for a time. Education of church leaders in the equal importance of both spiritual and social responsibilities is needed. Understanding of HIV/AIDS is broadening. A new and more complete understanding of the nature and effects of HIV/AIDS in the region has recently emerged. Beyond the physical effects, it is now recognized that a wide range of social, political, religious and economic factors are involved, with impacts on the psychological, emotional and spiritual lives of those affected. The Church has unique resources to address these total health issues in a holistic manner. Initial condemnation in the Church. Some in the Church initially believed that God’s plan for the world included HIV/AIDS as a scourge on those whose behavior was outside of Church teaching — as “just another in a string of disasters that must be withstood in preparation for the Second Coming, when humanity will be freed from the travails of this world.”7 This spiritualizing of the pandemic, still a factor 14
in many churches in the region, must be confronted and overcome if the Church is to play an effective role in this struggle. Vulnerability of women. Women’s increased vulnerability to HIV/AIDS presents a challenge to the Church. Nevertheless, some Catholic and Protestants groups are forging new paths for dialogue and progress between the sexes, where topics of sexuality, sex, pleasure and equity between the couple are discussed from the perspective of mature spirituality. The increasing incidence of The above issues illustrate not only the transmission among the heterodifficulties facing the Church, but also its potential strengths in working in sexual population demands that HIV/AIDS prevention and care. Some sectors of the Church will no doubt continue to be challenged to explain everyone become involved in and overcome their initial prejudice against people with HIV/AIDS. responding to HIV/AIDS. Many However, the reality of the pandemic is pressuring the Church in Latin America in the Church now see this realto modify its ways of responding. Now that there are many members of ity. A Chilean pastor addressed the Church living with HIV/AIDS, the Church will be even more motivated this point well with the admonito develop strategies to care for and include these individuals in the life of tion to his fellow pastors that, the congregation.The increasing incidence of transmission among the hetrather than condemning others, erosexual population demands that the Church should be studying everyone become involved in responding to HIV/AIDS. Many in the Church how HIV/AIDS can be used as now see this reality. A Chilean pastor addressed this point well with the “a chance to express the grace admonition to his fellow pastors that, rather than condemning others, the of God.”7 Church should be studying how HIV/AIDS can be used as “a chance to express the grace of God.”7 Social and Religious Context of HIV/AIDS in Latin America
It should be clear from the foregoing that the Church in Latin America has already been at least partially mobilized to tackle issues of HIV/AIDS. Yet much of the Church’s vast potential remains untapped to date — it remains to be seen what will be done to support and leverage this potential partner and resource in the future.
Religious-based initiatives are proving to be pivotal to the success of prevention and care efforts in Latin America as well as globally. Churches are found in nearly all communities in Latin America, and they wield a significant level of influence — culturally, politically, socially and educationally. Churches are usually respected in communities, and most have existing resources, structures and systems upon which to build. Recognizing these and other advantages provided by churches as partners in addressing health issues in the broader community, MAP International-Latin America has directed its efforts in recent years towards educating the Church itself on health matters, and challenging the Church to think more broadly about health development issues. A UNAIDS representative has stated the case this way,“Any government or organization fighting the Church institution is in a losing battle! The Church must be involved as part of the solution in development.”24 In this spirit, this “Any government or section argues that RBIs should increasorganization fighting the ingly be a driving force in the fight against HIV/AIDS in Latin America. Church institution is in a losing HIV/AIDS and battle! The Church must be the Church’s Mandate involved as part of the solution
An Untapped Resource In a practical sense, the Church can be in development.”24 viewed as the largest, most stable and most extensively dispersed non-governmental organization (NGO) in any country. It possesses human, physical, technical and financial resources needed to support and implement large-scale initiatives, and it can undertake these actions in a very cost-effective manner, due to its ability to leverage volunteer and other resources with minimal effort. Mainstreaming RBIs: Benefits at Low Cost
MAINSTREAMING RBIs: BENEFITS AT LOW COST
MAINSTREAMING RBIs: BENEFITS AT LOW COST
In recent years, many examples of the Church leveraging its resources against HIV/AIDS have developed in the region. In the Dominican Republic, for example, the nuns of the Religiosas Adoratrices care for women living with AIDS at the mission and visit others in their homes. Likewise, Christian health professionals in Santa Clara, Cuba, have formed a group of volunteers to undertake preIn a practical sense, the Church vention and care activities for people in their area living with HIV/AIDS. In can be viewed as the largest, Santiago, Chile, a Christian professor volunteers her time and teaching talmost stable and most ents at a local AIDS care organization. She tutors children, who are unable to extensively dispersed NGO in receive formal education because their families are affected by HIV/AIDS, links any country. It possesses these families with local churches and gives vitamins and food to the most needy families. human, physical, technical and financial resources needed to
Church members can provide a strong and motivated volunteer force in a community. Many programs in Latin America support and implement largegarner volunteers, of course, but these volunteers often have some expectation scale initiatives, and it can of receiving something for their efforts. Their action may come with some undertake these actions in a “strings attached.” In religious-based initiatives, volunteer activity has traditionalvery cost-effective manner, due ly been part of the culture of the to its ability to leverage volunChurch, and those who get involved generally work out of conviction alone, teer and other resources with with no expectation of pay or advancement. Worldwide, studies of RBIs and minimal effort. social action show that on average ten percent of a Church may become actively involved as volunteers.25 When this is compared with the usual two percent involvement of general society in volunteer actions or direct mail responses, the advantage of RBIs becomes clear. 18
These examples show that the Church possesses tremendous, yet underutilized, resources to respond to the HIV/AIDS pandemic. These resources should be more systematically mobilized in order for the Church to more fully recognize its powerful potential for service. Agents of Change: Religious Leaders Have a Powerful Voice in Society The important role of church leaders in society, evident in many parts of the world, is also visible in Latin America. A 1995 UNICEF article presents a compelling case in support of the influence that organized religion can make on “the priorities of society and the policies of leadership,” including the important area of health: Religion plays a central, integrating role in social and cultural life in most developing countries...There are many more religious leaders than health workers. They are in closer and regular contact with all age groups in society, and their voice is highly respected. In traditional communities, religious leaders are often more influential than local government officials or secular community leaders.26 The Church is an institution with longevity and stability, and it has existed in communities for centuries despite changing political and cultural situations.7 Overall, the Church has used the authority it carries to positively influence prevention efforts in the region. This is true despite the existence of more controversial situations, such as the case in Nicaragua where Church leaders opposed a particular public health prevention campaign due to moral misgivings about its promotion of condoms. The important contributions of the Catholic Church in designing HIV/AIDS legislation in Peru and El Salvador recently are illustrative of this point.14
Mainstreaming RBIs: Benefits at Low Cost
The Church’s Mandate to Promote and Care for Life The Church has an ancient biblical mandate to care for the health of the community. The Gospel of St. Matthew and many other Biblical passages call for the Church to be involved in the real, earthly issues of its community and to encourage behavior changes that safeguard health and defend life. Such a mandate is especially important in developing countries where basic needs are so visible and so extensive among populations with few economic resources. The two greatest commandments of the Church —“You The two greatest commandshall love the Lord with all your heart and with all your soul and with all your ments of the Church — mind . . . and you shall love your neighbor as yourself”— motivate the Church “You shall love the Lord with to outreach in the communities in which it is located as a means of demonstrating this love of God and of all your heart and with all your neighbor. This doctrinal basis can provide powerful motivation for HIV/AIDS soul and with all your mind . . . initiatives by Church groups. and you shall love your neighTangible actions of prevention and care that could be undertaken by nearbor as yourself”— motivate the ly any Latin American church in HIV/AIDS ministry include: Church to outreach in the communities as a means of demonstrating this love of God and of neighbor. This doctrinal basis can provide powerful motivation for HIV/AIDS initiatives by Church groups.
promoting abstinence and the delay of onset of sexual relationships, particularly among youth encouraging mutual marital fidelity caring for people infected with and families affected by HIV/AIDS providing psychological and pastoral counseling to family members educating children and the family in sexual issues
collecting donations to help cover medical treatment costs becoming involved with local human rights, labor or policy issues related to HIV/AIDS in a community27 The Role of the Church in Values and Behavior Change Experience has shown that changes in values and behavior are critical to slowing the spread of HIV/AIDS, and indeed, value modification and behavior change are closely related.28 Values that become internalized, such as those resulting from religious and spiritual conviction, can be powerful shapers of human behavior — both in life-affirming or negative ways. Perhaps more than any other societal group, religious institutions possess tremendous resources for fostering changes in values, and ultimately, changes in behavior. The moral resource of the Church can play a key role in shaping positive and life-giving behaviors in matters of sexuality, and even in drug abuse and prostitution — key areas in the struggle against HIV/AIDS. In the process of both challenging and building upon faith and belief, the Church can play a key role in discouraging high-risk behaviors and practices.Thus, the Church has an important function in molding values and behaviors that can affect the transmission of HIV/AIDS. It is essential, then, that groups like MAP International and other Christian organizations continue producing effective HIV/AIDS educational materials and providing training compatible with Church ethics. Religious-based initiatives should also continue to promote values that will bring about long-term, sustainable changes in high-risk behavior.
Mainstreaming RBIs: Benefits at Low Cost
The Church and Public Policy The Church can have a powerful and positive influence on health policy in countries of the region. As mentioned, the influence of the Church has not always been used in ways seen as constructive by policymakers. Yet on balance, the active presence of a strong moral voice in the region, through the Church, carries with it the potential of tremendous benefits for the society. The political strength of the Catholic and Protestant Church in Latin America gives it both the opportunity and responsibility to intervene with policymakers in helpful and constructive ways, geared toward the promotion of life-affirming and dignifying prevention and care efforts. The religious perspective can contribute to government prevention efforts in a variety of ways, including: Encouraging greater focus on belief and value change efforts. To date, for example, most government and internationallyfunded programs have focused on promoting the use of condoms, but few have tried to promote belief and value changes that would alter sexual behaviors.29 The promotion of condoms has been seen by some as the “foremost” strategy in prevention efforts.30 However, condom promotion is only one strategy, and there is room for the Church, with its focus on changing values, to complement these efforts with other methods.31 Promoting policy-making which includes the whole “family unit.” In many health policies and programs focusing on HIV/AIDS, the family seems to have been left out of the equation. This is quite short-sighted, since “families,” with all their varieties and extensions, are where values are initially formed. Indeed, the family is the basic unit of affection for individuals and communities. In situations where this affection is lacking, people may seek to replace it by engaging in brief sexual encounters that may put them at risk of contracting a STI, including HIV.35 Since one of the main roles of the Church is to strengthen the family, it can be an important resource for HIV/AIDS prevention programs that focus on 22
providing affection and sexual education within the family and on promoting safer sexual practices, such as marital fidelity. Promoting and providing access to care for those affected. Ideally, the Church — as a community of compassion and solidarity with those in need — can help provide care for individuals affected by HIV/AIDS, as well as help cover the costs of medical treatment. Government programs can and should leverage the resources of the Church, by virtue of its tradition of voluntarism and service, as a cost-effective way to encourage wider involvement in caring for those in need. The resources of the Church can be employed to develop sustainable strategies for enhancing support and participation in HIV/AIDS care activities. Working Hand-in-Hand Together to Stop HIV/AIDS Religious-based initiatives can complement current strategies in the fight against HIV/AIDS. The growth of the pandemic has led international organizations working in the field to search for a wide range of alternative prevention strategies to combat its spread. A report from the XI International Conference on AIDS presents information on the impact of prevention programs to date and draws the following conclusions regarding initiatives directed towards achieving behavior change in South America: While attention has been given to partner reduction, non-penetrative sex and the increase and correct use of condoms, programs have not fully capitalized on prevention messages addressing abstinence, mutual fidelity and delayed sexual initiation — messages which may be more aligned with the traditional/religious aspects of the region.22 Thus, RBIs are being recognized as key components in the fight against HIV/AIDS. Current methodologies and strategies are strengthened by their inclusion. In the early 1990s, for example, the WHO’s Global Programme on AIDS designed strategies for working with different sectors of the population. In Latin Mainstreaming RBIs: Benefits at Low Cost
America, the first sector chosen with which to work was the religious sector. According to Dr. M. Roberto Calderón, formerly the PAHO/WHO Inter-Country AIDS Advisor for Central America, Panama and the Dominican Republic,“this decision was taken considering some previous experiences that were encouraging and which convinced us that it was possible to take advantage of the important moral influence, spiritual influence and the influence on encouraging healthy social conduct that churches in all communities throughout the region exercise . . .”33 Based on this rationale, PAHO/WHO supported a series of innovative HIV/AIDS training workshops directed towards the religious sector in Central America and the Caribbean from 1993 to 1995. In May 1996, a similar workshop was sponsored by PAHO/WHO and convened by CAFSIDA. CAFSIDA is a network of Christian organizations working in HIV/AIDS in Ecuador that was founded, and for some years coordinated, by MAP International-Latin America. In the “First Encounter of the Religious Sector,” a consensus was reached among the Catholic and Protestant sectors of the Church in Ecuador to develop coordinated actions across denominational lines — a still too uncommon occurrence in the region. Activities that resulted from this joint PAHO/WHO and religious sector effort include the signing in December 1996 of an inter-ecclesiastical commitment to fight HIV/AIDS in the country and a training workshop for Catholic leaders from 24 dioceses directed by the Evangelical AIDS Network of Ecuador in September 1997. It should be clear from the foregoing that the contributions RBIs have brought to the HIV/AIDS struggle are unique and pivotal. As the on-the-ground examples in this booklet illustrate, Catholic and Protestant sectors of the Church in Latin America are responding to the needs of the affected populations with concrete actions that promote life in the face of the growing pandemic.
HIV/AIDS Challenges the Church In the course of formulating effective and appropriate responses to the HIV/AIDS pandemic, the Latin American Church has confronted numerous challenges. Even at this stage in the development of RBIs in the region, several significant challenges must yet be overcome by the Church and its partner organizations in order to maximize the Church’s potential contribution in Several significant challenges HIV/AIDS programming. At least two of these deserve special attention. must yet be overcome by the One is the need for institutional and structural change within the Church, Church and its partner organiand the other is the need for “limited domain collaboration” concerning prezations in order to maximize vention strategies adopted by RBIs. the Church’s potential contribution in HIV/AIDS programming. One is the need for institutional and structural change within the Church, and the other is the
Changes within the Church As RBIs in Latin America have begun to expand, it has become clear that even greater internal changes are needed within the Latin American Church for it to more fully participate in the struggle against HIV/AIDS. As a result of dialogue and education, however, changes are occurring.
need for “limited domain col-
Church leaders open to addressing HIV/AIDS have at times been afraid of censure by peers and, thus, reluctant to laboration” concerning prevenraise sexual issues.34 To admit that tion strategies adopted by RBIs. homosexuality or marital infidelity exists within a congregation may appear to some parishioners to mean admitting that the Church has failed in its mission — that of instilling Christian principles in its members. And some Church leaders, due to complex situations in their own lives, may fear being judged by the same standards of purity in sexual conduct they preach to others.
Mainstreaming RBIs: Benefits at Low Cost
Furthermore, Latin American Church leaders may hesitate to give comprehensive information on sexual issues to youth, ignoring the fact that 40 to 70 percent of these young persons may already be sexually active.35 Instead, leaders often “overspiritualize” the issues by presenting in isolation the argument that “the body is the temple of God” and must not be defiled. In doing this, Church leaders are missing a unique opportunity to encourage young people to assume responsibility for struggling with their own sexual decisions, and may, in fact, close the door to a dialogue with them on issues that they, too, find troubling. Christina Gutiérrez, a Christian woman involved in HIV/AIDS education efforts in Chile, concluded that many churches “don’t want to talk about AIDS because it means talking about sexuality, homosexuality, death — themes that make many in the Church uncomfortable.”7 Yet fear of these issues within the Church only harms the Church itself. The congregation knows the reality outside may not conform exactly to what a “fearbased” sermon may imply. Instead of strengthening the Church and enabling it to be the powerful behavioral change agent that it can be, this “fear” can make the Church less effective in HIV/AIDS prevention efforts. To combat this, programs and educational materials developed from a Christian perspective are critically needed. Especially in rural areas where materials are hard to find, Church leaders need this type of support as they strive to overcome these fears and develop their own activities in HIV/AIDS prevention and care. While most are prepared to share the Gospel, many lack the skills needed to design total health programs. In interviews conducted with Church leaders in rural areas, it was found that the desire to participate does exist, but without help from the outside, they do not feel prepared to create sustainable programs.34 For this reason, MAP International-Latin America and other Christian organizations around the region are producing HIV/AIDS materials with educational tools designed to foster long-term sustainable changes in high-risk behavior. The Church can use these tools to effect changes in values and overcome fears of sensitive topics. 26
Furthermore, education designed to encourage tolerance and compassionate care is still critical for church leaders and members of congregations who know little about HIV/AIDS. Resistance still exists within some Church congregations to show solidariGiven the diversity of opinions ty with, or to provide care for, people living with HIV/AIDS. These attitudes on HIV/AIDS prevention also must be confronted and overcome with education. strategies, creative solutions Toward Enhanced Diversity will be needed to develop space in Strategies to be Adopted by RBIs and Others for collaboration across lines of Given the diversity of opinion among churches (as well as between churches politics and world views. In the and governmental, non-governmental and multilateral organizations) on issues of HIV/AIDS prevention strategies, cre“limited domain collaboration” ative solutions will be needed to develop space for collaboration across lines approach, diverse partners of politics and world views. One approach that has been used successfulgather to address a particular ly in the United States to overcome this dilemma has been described by Rev. issue, agree to limit their range Gary Gunderson, Executive Director of the Carter Center of Emory University’s of cooperation to the issues at Interfaith Health Program, as “limited domain collaboration.” In this hand, and temporarily set aside approach, diverse partners who gather other areas of disagreement. to address a particular issue agree to limit their range of cooperation to the issues at hand and to temporarily set aside other areas of disagreement. This approach to collaborative partnership may hold great potential for avoiding undue tensions within the variety of diverse groups confronting HIV/AIDS in Latin America.
Mainstreaming RBIs: Benefits at Low Cost
The “first strategy” approach to the use of condoms has often served as a deterrent to more active involvement by the Church. This is regrettable since the Church is in a unique position to provide a single
One of the more contentious strategies for some segments of the Church is, of course, the promotion of condom use — a strategy not officially sanctioned by the Catholic Church and in some cases controversial within Evangelical Churches. According to Rosa Maria Dantas, an AIDS worker in Brazil, at times “governments have backed off from aggressive educational campaigns that might promote condom use and even from scientific education courses in public schools” in order to avoid confrontation with important Church leaders.7
coherent message of abstinence and fidelity in coordination — rather than in competition — with other prevention messages. The Church might be more open to promoting condom use as “one strategy among many” in specific high-risk instances, if the issue were defused of its volatility and tension.
For a number of years, disputes over strategies, ethics and tolerance issues have been a frustrating but expected part of partnership between the Church and governmental, non-governmental and multilateral organizations. While most organizations working in HIV/AIDS prevention recognize that the use of condoms cannot alone control the spread of the pandemic, many in the Church perceive that it is often the first or only strategy promoted by secular groups and, thus, view collaboration with these groups as a threat to their integrity. In Mexico, for example, Catholic bishops declined to join the efforts of CONASIDA, a group which has achieved great success in combining government and NGO resources in education and prevention efforts, precisely because the program promotes condom use as its “first strategy.”36 From the Church’s perspective, Religious-Based Initiatives
full participation in this program seemed to require compromise on a key ethical position — the delay of sexual intercourse until after marriage and the promotion of respect and fidelity within marriage. All branches of the Church do not speak with one voice on this issue, however. On one hand, some mainline Protestant churches are open to prevention strategies that include the use of condoms; while on the other, charismatic Evangelical churches tend to be less likely to discuss even relatively non-controversial issues surrounding sexuality, much less condom use. Officially, the Catholic Church does not sanction condom use under any circumstances, but paradoxically, some observers have noted that there seems to be more frank discussion about sexual issues and greater freedom to promote the Church’s role in addressing HIV/AIDS within local Catholic parishes. This may be a reflection of the Catholic Church’s broad history and experience of engagement in social action.37 It seems clear this “first strategy” approach to the use of condoms has often served as a deterrent to more active involvement by the Church, both Catholic and Protestant. This is regrettable since the Church is in a unique position to provide a single coherent message of abstinence and fidelity in coordination — rather than in competition — with the various prevention messages provided by others. And, at least a large segment of the Church would be more open to promoting condom use as “one strategy among many” in specific high-risk instances, if the issue were defused of its volatility and tension. If one spouse is HIV positive, or there is uncertainty regarding the sexual practices of a spouse, or Church members are otherwise putting themselves at risk through sexual activity, the Church has a responsibility to promote “life.” In these situations, this may mean discussing abstinence and at least explaining consistent and correct use of condoms, if not actually promoting them. Thus, while flexibility may be needed from the Church in these cases, multilateral, governmental and non-governmental organizations should capitalize on the positive health impact the Church’s message of abstinence in singleness and fidelity in marriage produces in the general society. Mainstreaming RBIs: Benefits at Low Cost
If the Church truly believes total health is more than the “physical condition” of an individual and true well-being includes emotional, spiritual, socio-economic, physical and environmental elements, promoting condom use is clearly not a comprehensive enough response to HIV/AIDS. It may be a practical and easy solution to a physical health risk, but it does not take into account the spiritual, social or emotional aspects that contribute to total health. Therefore, it is not in itself a sufficient response for
Condom use itself should not be seen so much as an issue of “morality,” but as a prevention strategy with limited scope. If the Church truly believes total health is more than the “physical condition” of an individual and true well-being includes emotional, spiritual, socio-economic, physical and environmental elements, promoting condom use is clearly not a comprehensive enough response to HIV/AIDS. It may be a practical and easy solution to a physical health risk, but it does not take into account the spiritual, social or emotional aspects that contribute to total health. For this reason, it is not in itself a sufficient response for the Church or religious-based initiatives. Therefore, strategies other than condom promotion should be considered by multilateral, governmental and nongovernmental organizations when designing prevention programs and messages for churches in Latin America. In doing so, all benefit from the single, coherent message the Church communicates. Above all, more discussion is needed to set ground rules for collaboration that allow all partners to maintain their ethical and strategic integrity in the search for effective means to prevent the spread of HIV/AIDS in Latin America.
the Church or religious-based initiatives.
In this section, we focus on actions churches are currently taking to combat HIV/AIDS throughout Latin America. Although religious-based initiatives are generally not well known, they are, in fact, having a profound effect on HIV/AIDS prevention and care in the region. A rapid assessment of the initiatives in place reveals the existence of numerous individual and coordinated activities in many countries of the region. The following models provide only a sample of the different types of RBIs presently underway in various countries. For ease of analysis, the models have been categorized as NGO programs, Church congregation or parish programs, network-based programs, hospital-based programs or international programs. NGO Programs: Local Capacity Building The Lutheran Church in Chile works through a local NGO, EPES (Educación Popular En Salud), to provide HIV/AIDS education to some of the poorest communities in Santiago and Concepción. They have created local neighborhood networks, called the Red Comunal El Bosque, that teach women how to develop HIV/AIDS education and prevention activities in their communities. In addition, the local neighborhood networks proactively assign women to various commissions (human rights, children, treatment), helping these women to build self-esteem and gain the courage to seek the support of their spouses in the fight against HIV/AIDS. A local NGO in Venezuela, Servicio Ecuménico Koinonia, offers HIV/AIDS workshops from a total health perspective and provides clinical, pastoral and family counseling. In its grassroots efforts with women, this organization focuses on two major issues: 1) building self-esteem through discussion of sexual and reproductive rights; and 2) improving awareness of the biological, social, economic and spiritual issues related to HIV/AIDS. Models of RBIs in Latin America
MODELS OF RBIs IN LATIN AMERICA
MODELS OF RBIs IN LATIN AMERICA
They also promote the creation of self-help communities to show solidarity with and minister to individuals living with HIV/AIDS and their families. For two years, Sociedad Internacional Misionera (SIM) in Ecuador has been providing HIV/AIDS prevention training in churches and schools, and through “community fiestas” in the marginal urban slums of Guayaquil. Using informal education techniques, over 50 of the participants in these workshops have become volunteer facilitators for other groups in their communities. Besides counseling people living with HIV/AIDS, they also provide short-term loans for HIV+ individuals to use as start-up capital in Five types of RBIs active small businesses. Surprisingly, after one of these young men died from in the region: AIDS, his family remained so grateful for SIM’s assistance that they repaid his loan post-mortem. NGO Programs: Local Capacity Building Church Congregation or Church Congregation or Parish Programs: Participatory Parish Programs: Approaches Participatory Approaches For a number of years, La Lucila Baptist Church in Buenos Aires,Argentina, has Network-Based Programs: sponsored a drug rehabilitation proCollaborative Action gram. Recently, they have realized Hospital-Based Programs: their work must also include services Care and Management for people living with HIV/AIDS. As ex-drug users became integrated into International Programs: Coalition Building the Church community, Church leaders discovered that a ministry to respond to the special needs of these individuals was required. In addition, Church leaders were faced with the task of helping others in the congregation overcome their fear of dealing with people living with HIV/AIDS. The leaders and members of the Lucila Church currently offer an integral HIV/AIDS program at the Hogar El Retoño hospice. The program includes self-help groups for people in residence who are living with HIV/AIDS, and a farm project that provides econom32
ic resources to help sustain residents during the later stages of AIDS when they are unable to bring in their own income. In Colombia, priests of the Eudista Congregation have provided hospice care for people living with HIV/AIDS for the past eight years. Furthermore, as part of the community outreach, they conduct education and prevention workshops in the community for people living with HIV/AIDS and their relatives. In Cuenca, Ecuador, Father Vega’s parish conducts similar HIV/AIDS prevention activities among recent immigrants to the area. El Pastoral del Buen Samaritano, a group associated with the Catholic Church in the Choluteca province of Honduras, educates community members on how to include issues of love and social justice when working with people living with HIV/AIDS. Their activities also include informational campaigns about HIV/AIDS, educational workshops, discussions on sexuality with married couples, and participation in World AIDS Day activities. Network-Based Programs: Collaborative Action The Ecuadorian Christian network, Coordinadora de Acción Frente al SIDA (CAFSIDA), exists to support and strengthen its member organizations, and it also provides a place for information exchange and collaboration. Furthermore, CAFSIDA works with local churches to encourage interdenominational initiatives and to increase awareness of HIV/AIDS. As of this writing, CAFSIDA is conducting a communication project entitled “Youth for Life.” HIV/AIDS prevention messages will be promoted through the airing of 50 radio spots on popular radio stations, the distribution of t-shirts during radio contests, and the sponsoring of a rock concert in Quito. In 1994, a Panamanian network of Christian organizations, Sector Religioso Contra el SIDA (SERECSIDA), arose from the 2nd HIV/AIDS Workshop for Christian Churches in Panama, sponsored by the Ministry of Health and PAHO/WHO. This network consists of members of the Baptist, Methodist,Assemblies of God, Salvation Army, Episcopal and Catholic Churches.Their objective has been to provide information on HIV/AIDS and to Models of RBIs in Latin America
train “multiplying” agents in prevention strategies through workshops, seminars and informal discussion groups. Furthermore, they have trained religious and lay leaders in how to provide pastoral counseling to people living with HIV/AIDS and their relatives. SERECSIDA also coordinates an HIV/AIDS prevention campaign among adolescents. Organizaciones Cristianas de Atención Primeria en Salud Integral (OCAPSI), a Dominican Republic NGO that unites churches of different Evangelical denominations to develop total health efforts, has focused much attention on HIV/AIDS through a number of activities. These include: providing hospital attention (including medicines and laboratory exams); counseling people living with HIV/AIDS and their relatives; facilitating educational workshops in several churches; directing seminars about how to show solidarity with people living with HIV/AIDS; and training pastors and Church leaders in how to provide counseling. A Guatemalan network, Programa Nacional Evangélico Contra el SIDA (PRONECSIDA), includes the Indigenous Evangelization Association,World Vision and the Evangelical Alliance from Guatemala, among other organizations. PRONECSIDA offers medical attention to those living with HIV/AIDS in Guatemala, produces written informational material, directs training workshops on HIV/AIDS prevention strategies and provides phone counseling. Hospital-Based Programs: Care and Management Hospital Voz Andes in Ecuador has an AIDS clinic that provides health care for people affected by HIV/AIDS, including the physical, spiritual, social and psycho-emotional elements. The program offers: on-going counseling; emotional/spiritual support and continuing education to people living with HIV/AIDS and their families; an interdisciplinary team of health professionals, including social workers and nutritionists, that provide advice and treatment; and frequent and appropriate outpatient medical care to avoid the high cost of hospitalization.
A health care center in Honduras, Hospital Evangélico, has designed a Community Service Program (PROSEC) which includes elements of HIV/AIDS education and care. This program offers HIV/AIDS information in a variety of settings, including sex education courses in local elementary schools, training workshops with local church congregations and continuing education courses for rural pastors. Plans are under discussion to begin self-help groups for people living with HIV/AIDS in the area. For the past 5 years, PROSEC has sponsored a national health educational workshop (attended by 120 Church leaders, students and health professionals in 1996) to discuss issues related to the family, sexuality and HIV/AIDS. The Capellanía Evangélica program instructs chaplains and therapy assistants in seven cities across Brazil in HIV/AIDS counseling techniques.The program trains close to 250 health counselors each year who work in public and private hospitals around the country. While the training is given to Christians and non-Christians alike, it provides a unique opportunity to encourage these counselors to adhere to ethical principles and offer loving care to people affected by HIV/AIDS. International Programs: Coalition Building The work of MAP International in HIV/AIDS prevention is illustrative of international-based programs that promote coalition building. Recognizing the Church’s need to confront HIV/AIDS and the potential impact of RBIs, MAP International-Latin America (MAP-LA) designed a multi-year HIV/AIDS initiative in 1992 that includes phases of bibliographic research and needsinvestigations, educational material production and training in prevention. These activities are coordinated with national Christian AIDS networks, such as those mentioned above. Elements of the program that have been implemented to date include: a research project to determine the needs of the Church leadership regarding HIV/AIDS; a review of the AIDS literature and educational materials in the region; an extensive knowledge, attitudes and practices investigation focusing on churches in Ecuador; a specific research project on the mobilizaModels of RBIs in Latin America
tion of the Christian Church in Honduras in preventing HIV/AIDS; and interviews with Christian leaders throughout Latin America. MAP International’s AIDS Bulletin now has a readership of over 10,000 in the region, and the phases of educational material production for high risk groups and supporting national AIDS networks are underway. Another recent initiative involved the partnering with local businesses and other NGOs to stage a rock concert in Quito to promote HIV/AIDS awareness and prevention messages among youth. These efforts have illustrated to MAP International and others that the majority of the Churches in Latin America are ready to confront the issue of HIV/AIDS and to initiate RBIs to address its effects. However, the RBIs need appropriate tools and support to take on this important task.Therefore, several international NGOs are partnering with government, other non-governmental, Christian and global health organizations in providing preventive training to Church, health and community leaders in many countries of the region. MAP International, for example, is presently partnering at various levels with other international organizations, such as the Salvation Army, Compassion International, UNICEF, PAHO, and FHI/AIDSCAP, among others. Several international para-church organizations, such as the Bible Society and Youth for Christ, have begun developing RBI efforts to confront the pandemic in the region as well. A key strength of international RBIs is that programs initiated in different parts of the world can benefit from the lessons learned in other regions. For example, MAP International-East & Southern Africa (MAP-ESA) in Kenya has been in the forefront of mobilizing and enabling churches from all major denominations to respond to the HIV/AIDS pandemic through networking and partnering, research on home care and behavior change, facilitation of policy formulation, material development and dissemination, and training of church leaders. Experiences and lessons learned from the MAP-ESA program continue to be shared and adapted extensively, especially by other MAP offices. MAP International has facilitated south-south exchanges through several initiatives, including: sponsoring a Peruvian pastor to attend 36
an African HIV/AIDS conference in Uganda; inviting MAP-ESA staff to visit the MAP-LA offices and participate in workshops in Ecuador; adapting and utilizing educational materials produced on different continents; and drawing African and Latin America leaders together to discuss global religious-based initiatives on HIV/AIDS during the past two International Conferences on Christian Health Ministry in the United States. Achievements of RBIs in Latin America These models point to the many achievements of religiousbased initiatives in the region. Foremost among these has been the Church’s ability to encourage voluntarism and leverage its vast resources in the fight against HIV/AIDS throughout Latin America. While this booklet does not give examples from every country of the region, each country contains Christian NGOs, churches or parishes, Christian networks, or Christian hospitals that have stepped forward to combat HIV/AIDS and to give hope to those who are affected by it. In general, efforts to sensitize society that good health includes more than just physical well-being have been quite successful. As these RBI models illustrate, health needs can be met effectively through the Church — those relating not only to spiritual health but also to family and emotional health. Through their holistic example, these RBIs are enriching other HIV/AIDS prevention and care efforts in the region. Each of the five types of models mentioned in the previous section has a unique subset of population with which to work, and each calls upon specific skills and resources to reach the “audiences” with messages. Each RBI must be based on the context of the community in which it works in order to direct its efforts and respond to the specific local needs. In Argentina, for example, HIV/AIDS prevention messages must include cautioning against needle-sharing due to the high rate of transmission through injection drug use in the country. RBIs, such as the work of La Lucila Church in Buenos Aires, have been very effective in the struggle against HIV/AIDS due to firsthand knowledge and understanding of the social, cultural and epidemiologic context in which they work. Models of RBIs in Latin America
NGO Programs At the grassroots NGO level, many Church pastors and priests now have changed attitudes towards people living with HIV/AIDS. They no longer view HIV/AIDS as only a “sinner’s pandemic.” These changed attitudes are directly related to the hard work of community, health and Church leaders in encouraging compassionate attitudes and loving action towards those affected by HIV/AIDS. Several of the models reflect critical actions being undertaken to focus on improving the self-esteem of women and men.These actions have helped improve relations between spouses and in couples. Furthermore, contrary to the cultural norm, they have challenged men to respect and value women more, particularly given a woman’s vulnerability to acquiring HIV/AIDS/STI.
Churches and parishes are filling an existing gap for people living with HIV/AIDS — that of responding to their spiritual needs and questions about suffering and death. A local church may be the only place where they receive
Local Congregations Some local congregations and parishes have initiated concrete religious-based initiatives, recognizing that, as a Church, they are called to witness — in word and action — the healing, love and hope Christ has to offer the people of Latin America and the whole world. These activities have included collaboration with civil society (nonreligious) efforts, including marches, all-night vigils, health campaigns and World AIDS Day celebrations. RBIs have also shown themselves to be cost-effective — in part because of the Church’s strengths in garnering volunteer participation.
understanding, compassion and profound answers to their complex questions.
Thus, churches and parishes are filling an existing gap for people living with HIV/AIDS — that of responding to their spiritual needs and questions about suffering and death. A local Religious-Based Initiatives
church may be the only place where they receive understanding, compassion and profound answers to their complex questions. RBIs can play an important role in the lives of individuals living with HIV/AIDS, especially in providing opportunities for dialogue on sensitive topics and true friendship. Network-Based Programs One of the most important achievements of RBIs to date has been the coordination of cross-denominational efforts by different institutions. The reality of HIV/AIDS has led Catholic, Evangelical and Episcopal churches to work together in Latin America and commit to concrete interdenominational actions, as illustrated by the network-based models. The network-based initiatives have provided opportunities for collaboration with governmental, non-governmental or multilateral programs that may have had reservations about working with an individual church due to differences in ideology. Thus, Christian networks have been able to work with non-Christian organizations to provide prevention and care messages that include ethical elements, even if the messages do not directly refer to the Church. Hospital-Based Programs Genuine interaction between health professionals and people from the religious sector has enabled both groups to see their work with people living with HIV/AIDS in a more integral manner. This collaboration is proving helpful in enabling medical personnel to recognize that people living with HIV/AIDS have a complex variety of needs that can only be met in a holistic manner, integrating spiritual and emotional health needs with the bio-medical ones. Through RBIs, health professionals have also recognized that when treating an individual who is living with HIV/AIDS, they must act morally above all else. Studying new AIDS drugs, conducting blood transfusions and developing safe dialysis procedures all challenge medical personnel to deal with ethical issues in a focused way that normally occurs only during the outbreak of a pandemic. Models of RBIs in Latin America
International Programs Regional efforts coordinated by international agencies or development organizations allow for the exchange of experiences and lessons learned. As different groups in Latin America learn of the successful elements of HIV/AIDS prevention and care programs in other parts of the world, these efforts can be adapted and replicated in the region. Likewise, the RBIs underway in Latin America have much to share with others concerning their experiences.
The previous sections point to many factors that should guide future policy making and joint efforts between the Church and multilateral, governmental and non-governmental organizations. Several specific lessons learned drawn from religious-based initiatives currently underway in Latin America in the fight against HIV/AIDS are summarized below: Despite many shared goals in the struggle against HIV/AIDS, a certain degree of mutual distrust remains between the Church and many multilateral, governmental and non-governmental organizations in Latin America. Some in the Church maintain that HIV/AIDS prevention programs have not generated actions or solutions addressing the root causes of the problem and/or the deepest needs of the population — solutions and needs that focus on changing values, beliefs and attitudes, such as promoting marital fidelity and encouraging communication and affection in the family. On the other hand, the perspective of some organizations has been that the Church has caused more harm than good in HIV/AIDS prevention efforts due to its resistance to certain prevention strategies, such as the promotion of condom use, and its promotion of moral and religious values that may not be shared by secular people. Neither of these interpretations is adequate or fair in isolation. Clearly there is much room for — and much to be gained by — closer cooperation and collaboration between these sectors. RBIs can have a powerful impact on public policy, and need to be mobilized as an important part of any HIV/AIDS policy efforts. Policy efforts will only truly take hold in society if they address the most critical issues facing those affected by HIV/AIDS — justice, dignity and care—issues with which the Church has Lessons Learned
long been involved.15 Since the opinion of the local medical community is usually one of the greatest determining factors in developing HIV/AIDS policy legislation in Latin America, RBIs could focus attention on educating this group in issues important to the Church. Education and exchange with media sources and other interest groups with influential voices should be encouraged, with the goal that these groups begin advocating for their common positions and actions in the many areas where there is unity, not division.14 Training materials that respect denominational and church context differences and that focus on topics of sexuality, counseling and pastoral accompaniment are proving effective in fighting HIV/AIDS. Given the difficulties of access to materials from the Christian perspective in the region, Church-based resource centers could fill a much-needed niche by offering up-to-date information on issues of practical use to local and community HIV/AIDS efforts. Further-more, research has shown that these materials are especially useful for rural Church leaders who are willing to undertake HIV/AIDS prevention programs but who do not feel prepared to do so without educational materials as guidance.38 The lack of accessible, educational materials from a Christian perspective is one of the main reasons many churches have not been able to confront their fears about HIV/AIDS and discuss sexual issues more openly with congregations. Positive changes in attitudes and perspectives have occurred in churches and other affiliated groups working on health issues in the region, but conceptual barriers to collaboration in HIV/AIDS work still exist in some churches. RBIs already working in HIV/AIDS can play a key educational role in facilitating further growth and openness within these Churches and institutions. Many churches in Latin America are increasing their openness to discussion of cultural and religious norms related to sexuality, especially as it relates to the foundation provided to fami42
lies, youth and children.34 Among church leaders, the emerging change of attitudes concerning sexual taboos and discussion of sexuality issues must be encouraged. Only by confronting the fear from which improper education is given will the Church learn to adequately deal with the reality of the surrounding community and its problems. The Church has a role to play in all aspect of HIV/AIDS prevention and care — not just spiritual issues but also those that address the social, economic, political, emotional and medical concerns intimately tied to HIV/AIDS prevention and care. The Church must see its mission as an integral one, and must not be afraid of becoming involved in the more complex aspects of HIV/AIDS efforts.The Church should work to encourage and strengthen a biblical model of the extended family as the fundamental nucleus of society and as a provider of affection. It must direct efforts to build the selfesteem of both women and men in order to change the cultural norms that encourage the spread of HIV/AIDS. RBIs in the region have shown the effectiveness of using various communication mediums and strategies to reach different segments of the population. RBIs should employ a variety of communication techniques in their efforts to educate the Church and society. The messages should focus on values and ethics without employing guiltinducing terminology. Channels to reach people include music concerts, cinema/video productions, drama presentations in parks, publishing articles in newspapers or magazines, and airing television and radio public health announcements. While these efforts may not even explicitly refer to the Church, the ethical principles contained in these messages can encourage the public to consider HIV/AIDS in an integral manner and can point to issues important to the Church.
Difficult ethical issues raised by certain strategies, such as the promotion of condoms as a “first strategy” or “one among many,” can be resolved sufficiently to allow for collaboration and compromise if addressed openly and with mutual respect. Ground rules for collaboration that allow all partners to maintain their integrity must be developed and agreed upon. Governmental, non-governmental and multilateral organizations should respect the ethical positions of the Church and take advantage of the Church’s message (abstinence in singleness and fidelity in marriage) in HIV/AIDS prevention and control programs. Similarly, the Church must be more flexible with respect to the condom issue. It must recognize situations, such as possible marital infidelity or one spouse living with HIV/AIDS, in which the condom may be the only viable option to support life, thus still keeping in line with Church ethics. Agreeing to limit the range of cooperation to the issue at hand and to set aside other areas of disagreement can perhaps defuse some of the tensions inherent in collaboration among diverse groups and foster cooperation. The strengths and achievements of RBIs to date can be the building blocks for future initiatives between the Church and multilateral, government institutions and NGOs in Latin America. The achievements of the models presented in this booklet in providing care for people living with HIV/AIDS should be celebrated, encouraged, publicized and shared with others. The interdenominational activities, the high rate of voluntarism, and changes in Church and health personnel towards a more holistic approach to HIV/AIDS are significant accomplishments and should serve as stepping stones for increased religious-based initiatives. Collaboration among churches can take the form of joint activities with neighboring congregations, and/or through networks with other Christian or multilateral, governmental or non-governmental organizations in a country. Especially critical for the Church’s involvement in 44
HIV/AIDS in Latin America is that this coordination reach beyond denominational boundaries to include all groups — Catholic, Episcopal, mainline Protestant and Pentecostal.The common language, culture, resources and boundaries shared by many of those living in the different countries in Latin America should be capitalized on in joint efforts between the religious and non-religious sectors. The commonalties have historically allowed for the discovery of related problems, needs and solutions, and for this reason, it has been “relatively easy to adapt and adopt experiences.”39 These shared elements allow for the identification of common problems and needs, but also for the discovery of common solutions to issues that affect everyone, like HIV/AIDS. Genuine debate and action concerning how the Church can best show solidarity with those living with HIV/AIDS and their families is sorely needed in many areas of the Church in Latin America. The Church should continue to convene leaders to discuss needs and implications of HIV/AIDS for the Church in Latin America, and to facilitate an understanding of the Church as a healing community in the region. The articulation of theological stances that encourage members to understand the holistic mission of the Church in society must be encouraged. Not only will this promote the viewing of HIV/AIDS as one of the Church’s responsibilities, but this can also encourage the Church to search for new opportunities of involvement in different areas of social action. The response of Christian communities to the HIV/AIDS pandemic should be based on compassion and a commitment to serve others. The Church must encourage and model tolerance and compassionate care for those living with HIV/AIDS. Resistance still exists within some Church congregations to the idea of providing care for, or including within the Church, people living with HIV/AIDS. Divisions within the Church itself that Lessons Learned
hamper loving or collaborative action must be addressed and overcome. Fidelity, the value of life, the importance of a person as a human being, self-esteem, responsibility, and the power of charity are all values and elements of church teachings that Christian communities have to offer those affected by HIV/AIDS.23 Only in promoting values based on love does the Church model the love of Christ.
The Church and multilateral, governmental and non-governmental organizations have a great deal to offer each other by partnering in the struggle against HIV/AIDS through religious-based initiatives. The Church can gain new tools, perspectives and partners with which to pursue its responsibility towards the community, and multilateral and other non-religious efforts can gain an effective ally in the Church — an institution with vast reach, resources and potential for impacting prevention and care in the region. The following are recommendations for future religious-based initiatives in HIV/AIDS prevention and care: Open dialogue and compromise are needed to replace any lingering mistrust and separation between the Church and multilateral, governmental, and non-governmental efforts. RBIs should be invited to participate more closely in the development of laws and policies impacting the issues surrounding HIV/AIDS, particularly as these policies focus on justice and dignity. Greater resources should be allocated for the production and distribution of educational and training materials specifically designed for use by Churches. As part of its efforts, the Church should continue to educate its leaders and congregation to be more open and receptive to working with the difficult and highly-charged issues surrounding HIV/AIDS. RBIs must take advantage of a variety of communication strategies and mediums, in both the religious and non-religious sectors, in order to be most effective in reaching a variety of populations.
Partnerships between the Church and multilateral, governmental and non-governmental organizations must be built on mutual respect, flexibility and the commitment to cooperate towards limited, mutually-agreeable goals. Enhanced coordination and networking within the Church and across lines of denomination and other barriers must be pursued vigorously. Additional resources and support should be allocated to those RBIs committed to the compassionate care of individuals living with HIV/AIDS and their families.
3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.
17. 18. 19. 20.
Development Associates, Inc. (1995). Management Review of the AIDSCAP Project. Washington: Development Associates. Family Health International/AIDSCAP (1997). Making Prevention Work: Global Lessons Learned from the AIDSCAP Project 1991-1997. Washington: Family Health International/AIDSCAP. “Holography.” Colliers Encyclopedia. 1996 ed. “Holography.” Encyclopedia Americana. 1997 ed. Babbie, Earl. (1992). The Practice of Social Research. 6th ed. Belmont, CA: Wadsworth Publishing Co. OPS/OMS. (1997). Vigilencia Epidemiólogica del SIDA en las Americas. Informe Trimestral de 10 de junio de 1997. Jeffrey, D. Paul. (1994). Latin America Confronts AIDS. AIDS, Ethics and Religion Edited by Kenneth R. Overberg. Maryknoll, NY: Orbis Books. Pacheco, Lucia (Ed). (1997). Situación de la Infección por VIH/SIDA en Honduras, Centroamerica.Tegucigalpa, Honduras: MAP Latin America. UNAIDS. (1996). United in Hope. Document distributed for World AIDS Day. AIDSCAP/LACRO. (1996). The Status and Trends of the HIV/AIDS Pandemic in South America.Vancouver, Canada: XI International Conference on AIDS. Aroney-Sine, Christine. (1995).Women and AIDS- An International Perspective. Daughters of Sarah Spring: 23. Naomi, M. MD (Sept. 1997). Personal Interview at the Clínica Nar by Anna Dulaney, Cañar, Ecuador. Martínez, Magdalena and de Cevallos, María Luisa. (1996). Unidas en la Esperanza. Boletín SIDA 5, 3: 1. Linares,Ana Maria. (1991). Legislative Approaches to AIDS in Latin America. International Law and Politics 23: 1016. De Llanos, Leda Bolaños. (1997). Un Decenio de Lucha Contra El SIDA: Situación Actual y Perspectivas de las ETS/VIH/SIDA en Honduras. Tegucigalpa, Honduras:AIDSCAP-Honduras. ONUSIDA. (1995). Modelos de Cooperación Técnica Entre La OPS y Los Programs Nacionales de Prevención y Lucha contra el VIH/SIDA en el Marco de ONUSIDA. Mexico City, Mexico. Ecuadorian Ministry of Health. (1997). Budget document. Quito, Ecuador. CEDHSIDA. (1996). SIDA:Temas Para el Debate. Salud Pública: Reflexiones y Experiencias. Quito, Ecuador: PAHO/WHO. Martínez, Magdalena. (1997). Por la Democratización de la Salud. Boletín SIDA. 6, 2: 5. Martínez, Magdalena. (1997). Anthropological Approach to the Relations of Power Between Advocates and Actors in HIV/AIDS Nearing the Year 2000. Quito, Ecuador: Universidad Politécnica Salesiana. Operation World. (1995). 20:21 Library Main CD-Rom, Global Mapping International.
22. Maldonado, Jorge (Ed.). (1992). Manual de Asesoramiento Pastoral a Personas Afectadas por el VIH/SIDA. Geneva, Switzerland: GMI. 23. Caritas Internationales. (1989). Consultation on AIDS: Caribbean Zone 6-10 July 1989. Castries, St. Lucia: Caritas. 24. Kiiti, Ndunge. (1996). Mobilizing African Know-How for Development. Proceedings of the Symposium on Integrating Africa into the Global Economy. Institute for African Development: Cornell University. 25. Simpson, Heather. (October 1997). Personal Interview by Anna Dulaney, Guayaquil, Ecuador. 26. Ebenezar, Reggie. (1995). Religious Leaders as Health Communicators. 1995 UNICEF Report. New York, NY: UNICEF. 27. Guzman, Rev.Anibal and Rev. Jose Luis Casal. (1991). Salud es Salvación Integral Quito, Ecuador: CIEMAL. 28. De Angulo, José Miguel and Stella. (1996). Como Facilitar el Aprendizaje de Valores para el Desarrollo de Conductas Saludables en las Personas. Cochabamba, Bolivia: MAP-Bolivia. 29. FEIM. (1997). Desidamos May: 1-5. 30. Bradshaw, Lois E. (1991). International AIDS Prevention and Control: Overcoming the Obstacles International Law and Politics, 23, 1038. 31. Padilla, C. Rene. (1994). La Iglesia Frente al SIDA. Discipulado, Compromiso y Misíon. San José, Costa Rica:Visión Mundial. 32. Solís, Mauricio. (Sept. 1997). Personal Interview by Anna Dulaney, Quito, Ecuador. 33. PAHO. (1995). The Response of Central America to HIV/AIDS:The Impact of the Mobilization of the Religious Sector of Society. San José, Costa Rica, OPS/OMS. 34. Ayála, Raúl. (Ed). (1994). Family Congress on HIV/AIDS and the Church. Interviews with 50 Regional Church Leaders, Quito, Ecuador: MAP Latin America. 35. Martínez, Magdalena. (1996). The Construction of Imagery in Sexuality and HIV/AIDS in Leaders and Youth of the Baptist Church. Quito, Ecuador, University Politécnica Salesiana. 36. CNN Report, 26 August 1997, Ecuadorian television station TeleAmazonas. 37. Patpatian, Jorge and Torko, José. (1997). SIDA: Una Perspectiva Medica y Cristiana. Montevideo, Uruguay: Editorial ACUPS. 38. Ayála, Raúl, MD. (Ed). (1994). Position of the Church Facing HIV/AIDS in Latin America. Unpublished Research, MAP Latin America, Quito, Ecuador. 39. PNUSIDA. (1996). Strategic Planning document of PNUSIDA. New York, NY. Other works consulted: Martínez, Magdalena (Ed). expected 1997. Women and the Church in the Struggle Against HIV/AIDS in Latin America. Educational packet, MAP Latin America, Quito, Ecuador. Perez, Loida. (1997). First Training Workshop in AIDS Information, Education and Communication of Pastors and Lay Leaders of the Christian Church. Santo Domingo, Dominican Republic, National AIDS Program.
Family Health International (FHI) is a non-governmental organization that works to improve reproductive health around the world, with an emphasis on developing nations. Since 1991, FHI has implemented the AIDS Control and Prevention (AIDSCAP) Project, which is funded by the United States Agency for International Development (USAID). FHI/AIDSCAP has conducted HIV/AIDS prevention programs in 40 countries, and the Latin America and Caribbean Regional Office (LACRO) has implemented interventions in 14 countries within the region.
November 1997 For further information, contact: Latin America and Caribbean Regional Office AIDSCAP/Family Health International 2101 Wilson Blvd, Suite 700 Arlington,VA 22201 Telephone: (703) 516-9779 Fax: (703) 516-0839 Graphic Designer: Deborah Clark