Conflicts between conservative Christian institutions and secular groups in sub-Saharan Africa: Ideological discourses on sexualities, reproduction, and HIV/AIDS

Abstract

Religious and secular institutions advocate strategies that represent all points on the continuum to reduce the spread of HIV/AIDS. Drawing on an extensive literature review of studies conducted in sub-Saharan Africa, we focus on those secular institutions that support all effective methods of reducing HIV/AIDS transmission and those conservative religious institutions that support a limited set of prevention methods. We conclude by identifying topics for dialogue between these viewpoints that should facilitate cooperation by expanding the generally acceptable HIV/AIDS prevention methods, and especially the use of condoms.

Introduction

Societies have traditionally granted broad authority to religious institutions to create and oversee rules for many aspects of individual behaviour, including those affecting sexuality, the role of women, reproduction, health education and care of the sick. Yet religious institutions vary in how they view these issues. Some rely on Holy Books for their authority and are resistant to change, while others are morally closer to liberal secular groups. Because HIV/AIDS risk-reduction is inextricably intertwined with the rights to sexual and reproductive autonomy as well as freedom from discrimination of sexual orientation and gender, societal policies and actions on HIV prevention are divisive. In this paper, we focus on sub-Saharan African conservative churches and their leaders who support only those HIV/AIDS prevention methods proscribed by Holy Writ (Pfeiffer 2004) and tradition. We compared this prevention approach with those groups who we characterise as secular, and who accept as a human right, all HIV/AIDS prevention methods. Conservative religious organisations include Evangelical, Fundamentalist, Charismatic, Pentecostal and Roman Catholic churches.

In the last two decades, conservative Christian institutions, sometimes spurred by government funding, have imposed their moral judgments on HIV/AIDS prevention (Gusman 2009, Prince et al. 2009). Conservative religious and secular institutions have disagreements concerning abstinence, premarital and extramarital sex, contraception and homosexuality. The resulting clashes are identified in our literature review of published English-language and grey literature between 1995 and 2011. We searched electronic databases, including PubMed, Medline/PsychInfo, ProQuest, American Theological Library Association, Humanities, New/Old Testament abstracts, Religious & Theological abstracts and Google; terms included: religious institutions; reproduction and sex; religious institutions and condoms; religious institutions, conception and HIV; as well as human rights and religion. We also reviewed the bibliographies of all articles to identify additional references. This process yielded a total of 100 articles. We conclude this analysis with a discussion of how secular and conservative religious institutions might join together to increase HIV/AIDS prevention initiatives.

Secular and religious collisions regarding sexual and reproductive rights

Early Hebrews linked reproduction with survival (Yarber 2010), disapproving of all sexual activity not aimed at reproduction. Many conservative Christian institutions maintain adherence to this restrictive perspective (Marsden 2006, Bottum 2008). Secular institutions, drawing upon philosophy, moral reasoning and science (Center for Health and Social Policy 2005), believe that the four sexual human rights -- sexual autonomy, access to HIV/AIDS risk-reduction information, reproductive autonomy, and freedom from stigma and discrimination of sexual orientation and gender -- are needed for effective HIV prevention. Some conservative Christian institutions have adopted limited revisions of their traditional approaches to sexual and reproductive health behaviours in response to the HIV/AIDS epidemic. As Gordon and Mwale (2006, pgs. 71-72) state: ‘Faith-based organisations have always struggled with how to marry their moral mission and the need to protect health and life, given the reality of people's sexual lives’. The teachings of religious institutions on moral issues are in theory universal and unchanging. Professor of Philosophy John Lamont (2010, p. 24) at the University of Notre Dame in Australia states, ‘there is no sociological theory or sociological evidence to support the claim that religions can preserve or increase their influence while lowering their standards and submitting to the society around them’. He observes that mainstream Protestant churches that make few demands on their members are declining, whereas more demanding Evangelical and Pentecostal churches are growing in sub-Saharan Africa. In practice, this concern with the consequences of ‘lowering’ standards has led conservative religious institutions to resist any change for fear of diminishing the size of their congregations.

Unsurprisingly, neither conservative Christian institutions nor secular groups accept the other's definition of sexual and reproductive rights. As Bayes and Tohidi (2001, p. 5) note: ‘The struggle is between those who define gender roles and sexuality on a fixed hierarchical order, often sanctioned by religious doctrinal necessity, as predetermined by divine and/or natural order, and those who view these as matters of social-historical construction and individual choice’. We believe that it is important to help the conservative religious teachers to limit the spread of HIV/AIDS.

Linking sexual and reproductive health with a ‘human rights’ perspective has broadened the secular discourse from being judgmental (AIDS is punishment for sexual immorality) to embracing empowerment and challenge of social injustices (Schmid 2006). The landmark 1994 International Conference on Population and Development (ICPD) and 1995 Beijing Platform of Action at the Fourth World Conference on Women signified for many a global secular recognition of sexual and reproductive health rights. These rights have been reaffirmed by many other groups, such as the World Health Organization, United Nations Population Fund, and the Protocol on the Rights of Women in Africa (Center for Reproductive Rights 2006). A landmark decision by the Human Rights Committee in Australia in 1994, Toonen v. Australia, argued that non-discrimination provisions regarding sex included sexual orientation (Saiz 2004). In 2007, the Yogyakarta Principles on the Application of Human Rights Law in relation to Sexual Orientation argued for the protection of privacy rights for all, regardless of sexual orientation or gender identity (O'Flaherty and Fisher 2008).

Although secular organisations hold that reproductive and sexual rights (e.g. abortions for HIV-positive pregnant women) should be universal, some conservative religious institutions actively contest these ‘human rights’ (Miller 2000). The manner in which countries tackle these issues are dependent on laws enacted to address local secular and religious values. For some of these secular groups, the refusal of Catholicism and Islam to condone family planning and abortion is based on their shared vision of women as inferior and men as in charge (Kissling 1994-1995), and perhaps also on social control of sexuality.

Below, we explore how religious doctrines of conservative churches frequently conflict with the four ‘human rights’. We present biblical citations that these churches rely upon and findings from empirical studies.

1. The right to sexual autonomy

Heterosexual sex within marriage is the accepted, if not celebrated, expression of sexuality within the vast majority of Christian traditions (Louw 2008). A number of passages in the New Testament speak to the sanctity of marriage and prohibitions against sex outside of marriage.

Marriage [is] honourable in all, and the bed undefiled: but whoremongers and adulterers God will judge. (Hebrews 13:4, King James Version, http://kingjbible.com/hebrews/13.htm.)

Now the works of the flesh are manifest, which are these, adultery, fornication, uncleanness, lasciviousness....they which do such things shall not inherit the kingdom of God. (Galatians 5:19-21, King James Version, http://kingjbible.com/galatians/5.htm.)

According to conservative churches, the only HIV/AIDS prevention method condoned by these biblical passages is sexual activity within marriage (Obaid 2005, Morgan 2009). Premarital abstinence and marital fidelity, the only acceptable norms, vary greatly with culture, tradition and economy (Benn 2002). Unfortunately, with the demands of separation for work, exemplified by migrant labour and military service, the preservation of fidelity has seldom proved realistic, and considerable research on sexually transmitted infections bears evidence to this (Lurie et al. 2003). Multiple Demographic and Health Surveys in sub-Saharan Africa indicate that sex with a non-spouse or non-cohabiting partner is common – e.g. 11% among Nigerian men (Mitsunaga et al. 2005), 19% among married Zambian men (Kimuna and Djamba 2005), and 21% among Cameroonian (Kongnyuy and Wiysonge 2007) and South African men (South African Department of Health 2007).

Interpretations regarding sexual autonomy vary by and within Christian denominations. In Evangelical, African Independent, and Mainline churches, many of which are fervent in their adherence to traditional interpretations of the New Testament, extramarital sex is viewed as a sin that imperils salvation (Gennrich 2004). In D.J. Smith's study (2004, p. 430) of rural-urban migrant Igbo Nigerian youth, Pentecostal and other ‘Born Again’ pastors viewed HIV/AIDS as a ‘scourge visited by God on a society that has turned its back on religion and morality’. In the words of one of Smith's female participants,

...this place is like Sodom and Gomorrah. Nigerians are being punished for their sins. If people did not have sex here and there, if the society were not so corrupt, there would be no AIDS...Yes, it is God's punishment, but we have brought it on ourselves.

Smith (2004) categorised the religious views affecting sexual behaviour among these Nigerian youth as abstinence, moral partnering (sexually active but based on monogamy and religion) and denial (pre- and extramarital relationships are rationalised, hidden and denied). Unfortunately, the youth who adopted moral partnering were convinced that they were unconcerned about HIV/AIDS (because they trusted their partners also to limit their relationships) and therefore did not need to use condoms with a moral partner.

Some conservative Christian churches frame sexual intercourse as a sacred aspect of life, viewing it as a manifestation of God who evokes his presence within the sexual union of each married couple. Premarital sex is a defined sin; premarital virginity is equated with purity. Premarital sex, homosexual sex, and sex work are labelled by many conservative Christian churches as failures of the flesh, sins of impurity. Members of these religious communities who choose to adopt any of these behaviours unsurprisingly do not seek information on protecting themselves from HIV for fear of exclusion from their church (Denis 2009).

The willingness of Christian pastors to incorporate HIV/AIDS messages into their sermons varies widely. In 85 churches and mosques in rural Malawi, about 30% of religious services referred to HIV/AIDS (Trinitapoli 2006). Abstinence and fidelity were the second most common themes to those of repentance and salvation. Indigenous Church leaders in an urban area in KwaZulu-Natal, South Africa, recognised the need to speak about HIV/AIDS, but were reluctant to discuss this topic from the pulpit because of cultural constraints in talking about sex in a public forum. Similarly, in an ethnographic study of university students from an urban Pentecostal Church in Kampala, Uganda, the ideals of abstinence and fidelity were preached (Sadgrove 2007). In the words of one pastor:

Sin is a big problem to God and Christians. The condomised culture is becoming normal but we stick to abc — Abstinence, Be faithful, Christ! — as the answer. People pump it ‘it's ok as long as you use condoms’. No! the condom culture is not the kingdom culture.

Religious condemnation of sex outside marriage is believed to be effective in reducing sexually transmitted HIV infection (Gregson et al. 1999, Garner 2000). Through in-depth interviews and household visits, Garner (2000) examined the effects of conservative Christian institutions on members’ sexual behaviour in a peri-urban community in KwaZulu-Natal, South Africa. He outlined four mechanisms used by these religious institutions: (1) indoctrination; (2) fostering moral conformity through participation in church activities and mobilising social capital through youth groups and camps; (3) maintaining fidelity through fear of exclusion; and (4) educating its followers. The importance of the four mechanisms varied across denominations and time. Pentecostal church members had significantly lower levels of extra- and pre-marital sex and were the least likely to have an illegitimate child. Similarly, in a study in Malawi, male members of Pentecostal churches had a lower level of perceived HIV risk and risk behaviours (Trinitapoli and Regnerus 2006). In Ghana (Luginaah et al. 2005) and in East Africa (Gusman 2009, Parsitau 2009), mandatory HIV testing has been used by some churches for couples intending to marry so as to ‘save innocent men and women’. However, Campbell and colleagues (2010) note that such social control can be a double-edged sword, reinforcing and maintaining gender relations that disadvantage women's ability to negotiate safer sex. This contradiction was also noted in Sadgrove's (2007) study of Pentecostal university students in Kampala, Uganda, as well as Mate's (2002) study of Pentecostal churches in Zimbabwe.

One key unanswered question is whether strict norms about pre-marital abstinence and marital fidelity and advocacy for the ideal of sexual restraint result in less risky behaviour among members of conservative religious institutions. The studies described above suggest that membership in evangelical/Pentecostal churches may be protective against HIV; however, the pathways to explain the links between HIV risk perceptions and risk behaviour are unknown. There are several possible reasons to support this protective effect, including negative consequences of nonadherence to behavioural expectations of no sex outside of marriage; indoctrination into church's world view of strict moral codes and socialisation within restricted social networks; and social control.

2. The right to HIV/AIDS risk-reduction information

The consensus at the 2001 United Nations General Assembly Special Session on AIDS was that there is the need for a comprehensive package of HIV/AIDS risk-reduction interventions. This call was ignored by the Bush administration in excluding all scientific references to the efficacy of condoms from US government programmes and websites (Meckler 2002, Human Rights Watch 2004). This omission served to increase scepticism among public, religious and governmental institutions about which components of the ABC approach (Abstain, Be Faithful, and Condom Use) to HIV/AIDS prevention should be endorsed (Green et al. 2006).

There appear to be two reasons why conservative Christian religious institutions continue to oppose condom use. The first is that many rely on statements in the Old Testament, e.g. be fruitful and multiply (Tharao et al. 2006), while secularists believe that the Biblical proscription to flourish is better achieved by restricting the quantity and quality of childbearing. Since condoms remain a key component of all HIV prevention strategies endorsed by secular groups, we analyse the objections to their use in relation to contraception; to promiscuity; to sex education in the young; to church leadership; and to harm-reduction for HIV. Lastly, we consider signs of variation and change in the positions of some religious groups.

Religious opposition to condoms

Clement of Alexandria (AD195) wrote, ‘Because of its divine institution for the propagation of man, the seed is not to be vainly ejaculated, nor is it to be damaged, nor is it to be wasted’. The Catholic Church refined this concept 60 years ago when it promulgated ‘natural’ family planning (‘rhythm method’) as the only approved means of regulating procreation (Pope Pius XII 1951). However, introduction of the effective birth control pill 50 years ago revolutionised family planning, as many perceived it to be more protective and sexually satisfying than the rhythm method.

The second reason they oppose condom use is the fear it will encourage promiscuity (Krakauer and Newbery 2007, Foster et al. 2009, Aguwa 2010). In a world with lifetime mutual monogamy, virtually all sexually transmitted diseases would be eliminated. Unfortunately, throughout recorded human history, societies have been unsuccessful in imposing this stance.

Condoms and sex education for the young

Conservative Christian religious institutions that promote abstinence and fidelity believe that these practices prevent new infections, frequently citing Uganda as the exemplary model (Denis 2003). Programmes, whether school-based or government-sponsored, that promote abstinence- only are out of touch with the reality that many young people throughout sub-Saharan Africa are sexually active before marriage, and they withhold access to comprehensive sex education (Santelli et al. 2006). For example, nearly 40% of women and 40-45% of men in sub-Saharan Africa have had sex by age 18, and more than 75% of women and more than 60% of men, by age 20 (Biddlecom et al. 2007). Clear evidence is found in many societies that abstinence-only programmes are less effective in delaying or reducing teenage pregnancy than are ‘abstinence plus’ programmes that use a hierarchical approach that promotes abstinence first but also condoms and contraceptive information (Perrin and DeJoy 2003, Dworkin and Santelli 2007, Kirby et al. 2007). This is good news for preventing teenage pregnancy but also for reducing disease transmission. The inflexibility of religious precepts of conservative Christian churches suggests the need for secular groups, e.g. schools, to encourage educators to refine their definitions of moral precepts to protect young people against AIDS. Restrictions on access to HIV/AIDS information and condoms impede public health and, in turn, the right to protect health (Human Rights Watch 2004).

A Seventh Day Adventist Church in Zimbabwe punished five youth members by suspending them from a gathering when condoms were discovered in their cabins. This church believes that condom use leads to promiscuity, which is seen as a violation of the sixth commandment (Makahamadze and Sibanda 2008). As the Pastor and camp's Youth Director said, ‘If the health workers come to teach about HIV and AIDS and the risks associated with it, I will welcome them. But if they talk about condoms, I will tell them to go to hell’.

Church leadership

Interviews conducted with 117 church ministers, lay leaders, people living with HIV/AIDS (PLWHA) and caregivers of PLWHA from 30 mainline, Pentecostal/Evangelical, and African Independent churches in Pietermaritzburg, South Africa, showed that ministers and lay leaders were far less accepting of condom use than PLWHA or their caregivers (Gennrich 2004). Two-thirds of ministers and half of lay leaders opposed condom distribution in church halls. In addition, ministers and lay leaders did not consider condoms to be a useful strategy for preventing HIV/AIDS, although a few did suggest that congregants use condoms. Among PLWHA, 11 viewed their churches as promoting condoms, 9 believed their churches opposed condom promotion, and 13 said their churches were silent about their position on condom use. Discussions with PLWHA and their caregivers indicated that even though they were more accepting of condom use, distribution of condoms would conflict with the churches’ message of abstinence and recipients might be labelled as promiscuous. In 16 semi-structured interviews on HIV prevention with Catholic, Evangelical Lutheran, and the Assemblies of God clergy in South Africa, religious leaders faced three dilemmas in their approach to HIV/AIDS prevention messages: the clergy's breaking the silence on HIV/AIDS; HIV/AIDS prevention messages being misconstrued by or inappropriate for young people; and gender different-prevention messages (Eriksson et al. 2010). These interviews indicated that talking openly about sex, HIV, and condoms — ‘unbiblical things’ — might provoke conflict between the church leaders and the church hierarchy and resistance from congregants. To break this silence, some church leaders reported they encouraged HIV testing during premarital counselling, but expressed ambivalence about HIV prevention messages for youth due to the belief that parents are responsible for such sexual education and the taboo of talking about sex in public venues. Church leaders with negative attitudes about condoms would support condom use only among married HIV-discordant couples and people who were non-church goers. Leaders with positive attitudes cited ‘taking precaution’ and ‘using protection’ rather than mention the word ‘condom’. Although church leaders claimed that they believed in gender equality, the HIV prevention messages some promoted were contradictory, e.g. that only a woman needs to be ‘strong enough’ to refuse sex with men other than their spouse.

Variation and change in religious institutions

In his first visit to Africa in 2009, Pope Benedict XVI stated that HIV/AIDS cannot be overcome through the distribution of condoms. More recently, the Pope's stance on denouncing condom use in all cases as an instrument of immorality has shifted to accepting the need for condoms for reducing the risk of infection in some circumstances, such as by male sex workers (Donadio and Goodstein 2010, Holden 2010). The Pope's current position is a demonstration that the Catholic Church can change its moral reasoning in response to people's health issues. Yet, even with the Pope's acceptance, some church leaders, such as the Cardinal of the Kenyan Catholic Church, continue to vociferously oppose condom use for any reason (PlusNews 2011). Others in Africa have taken a ‘don’t ask, don’t tell’ approach to condom use, where the church is seen as ‘promoting prostitution’ if it allows people to use condoms. And even though most churches do support condom use, it is with the understanding that each individual must choose for themselves. Similarly, Father Chris Townsend of the South African Catholic Bishop's Conference said, ‘In South Africa it's our approach that we will teach people about condoms. We don't encourage them but we don't discourage them’. Father Townsend's rationale, which was supported by a number of African Catholic priests, that not opposing is not encouraging condom use, observes the form of the doctrine of Papal condemnation of general condom use (Kardas-Nelson 2009). Governmental HIV prevention strategies may conflict with religious organisations, as illustrated in a study of mainstream Christian, Pentecostal and Muslim religious leaders in Malawi (Rankin et al. 2008). Interviews with 40 religious leaders from five institutions indicated that the government's promotion and distribution of condoms as part of the ABC approach were in direct opposition to the stance of all religious institutions’ on premarital abstinence and marital fidelity, characterised as the ‘condom divide’. Their condemnation of condoms was based on the belief that promoting condom use gives people the license to sin and threatens the moral values central to their faith. Similarly, the Jeito brand condom social marketing campaign became a source of contention with religious leaders in Mozambique who viewed condom promotion as clashing with hegemonous church morality (Pfeiffer 2004).

Harm-reduction

Some leaders of conservative Protestant churches in rural Malawi equate condom use with being ‘Satanic’ (Trinitapoli 2006, 2009). Other religious leaders were more accepting of condom use as a contraceptive for marital partners and for people unable to abstain from sex, though they seldom preached this message from the pulpit. In Kenya, some Islamic religious leaders, relying on the ‘lesser of two evils’ principle, permit the use of condoms based on their benefit of reducing the spread of AIDS (Maulana et al. 2009). Commitment to a harm-reduction concept has also been reported in a study of church leaders and congregants in Pietermaritzburg, South Africa (Gennrich 2004). As one congregant reported, ‘We are losing people we love and care for. We know condoms are not 100% safe but we are committed to reducing the spread of the virus. [Our] Canon ... helped me to sort out my thinking about condoms. He is very clear that condoms are important for all - including married couples - and they are not just a license for promiscuity, but a sensible tool to reduce the risk of spreading HIV in a society that puts all kinds of pressures on people to engage in sex, whether it is their choice or not’.

In light of the high number of HIV infections within Southern Africa, the South African Catholic Bishop's Conference asked the Vatican to review the stance on condoms as a preventive measure, ‘particularly in situations where one person in a marriage is HIV-positive, and the other is HIV-negative’, says Father Townsend (Kardas-Nelson 2009).

3. The right to reproductive autonomy

Religion plays an essential role in how people understand and make choices about contraception, fertility, motherhood and abortion. Many Christians interpret the New Testament as valuing the dignity of every person, love and compassion of God, and the rights and responsibilities of members of a society. The Catholic Church encourages reproduction within marriage, but is not explicit, and is even self-contradictory, in its position toward non-reproductive sex. For example, is sex permissible for the sole purpose of pleasure? The Bible encourages sexual pleasure:

Let her be as the loving hind and pleasant roe; let her breasts satisfy thee at all times; and be thou ravished always with her love (Proverbs 5:19, King James Version, http://kingjbible.com/proverbs/5.htm).

...Let him kiss me with the kisses of his mouth: for your love is better than wine (Song of Solomon 1:2, King James Version, http://kingjbible.com/songs/1.htm).

Catholic ideology maintains that sex is only allowed for procreation purposes, but peculiarly approves the rhythm method. Other than abstinence, Catholics are likely to have difficulty reconciling Humanae Vitae Encyclical and the advice by secularists given to HIV-positive individuals about sexual decisions. How do HIV-discordant couples prevent the spread of HIV/AIDS to their uninfected partner and their unborn foetus? Married HIV-positive individuals unaware of their partner's HIV status, and women who unintentionally become pregnant face the complexity of dealing with the HIV status of a foetus.

Mate's ethnographic study (2002) of Pentecostalism in two women's organisations in Zimbabwe describes how the ‘Born Again’ discourse exalts motherhood, viewing it as God's work, God's plan for women, God making miracles, and surrendering to God. In contrast, contraceptive use is defined as breaking the shroud of motherhood. Thus, Pentecostal religious ideology considers all pregnancies to be desirable and abortion a non-viable option. This deification of fertility denies women control over their bodies. Fertility is viewed as a way to sustain marriage and demonstrate self-worth, whereas infertility and miscarriage are associated with being the devil's work and a justification for men to divorce, have multiple marriages, and engage in extramarital sex.

Secular groups deem it appropriate for both partners to have equal rights to decide family size. Decisions are reached in the context of our understanding of biology and, to a lesser extent, demography and social sciences. From a ‘human rights’ perspective, women's ability to control their fertility could reduce maternal and child mortality (Freedman et al. 2005).

4. The right to freedom from stigma and discrimination of sexual orientation and gender

Sexual orientation

Conservative religious institutions often promulgate rigid norms of sexual identity (Horn 2010), supported by an ideological stance that homosexuality is sinful. The Old Testament clearly condemns homosexuality.

Thou shalt not lie with mankind, as with womankind: it is abomination. (Leviticus 18:22, King James Version, http://kingjbible.com/leviticus/18.htm).

Religious traditions are often used to justify laws and judicial decisions as well as discrimination against sexual minorities (EHAHRDP 2007). Policies and laws have been adopted that exclude protection of the individual rights of people based on their sexual orientation (Twiss 1998). According to the International Lesbian and Gay Association, among 242 countries, 78 have laws that criminalise male same-sex relationships and in 45, female same-sex relationships are illegal (International Lesbian, Gay, Bisexual, Trans and Intersex Association 2008). In parts of sub-Saharan Africa, authorities relying on religious laws impose whipping, life imprisonment, and even death penalties. When same-sex relationships between consenting adults are criminalised, fear of jail, violent attacks, stigma, and discrimination reduce the number of gay people who choose to be tested for HIV.

Although alternative sexualities are known to have existed in sub-Saharan Africa for at least 400 years, many people today have highly negative attitudes toward sexual minorities, attributed to both retained colonial laws and values and powerful religious beliefs (Oxfam 2010). Two widely publicised events provoked a secular outcry in support of same-sex partnerships in sub-Saharan Africa (Senior 2010). The first occurred in Malawi, a deeply conservative society where traditional religions are mixed with the values of the Anglican Church. Based on the country's ‘decency’ law, a 14-year jail sentence for sodomy was imposed on two homosexual men who underwent a same-sex commitment ceremony, but they subsequently received a presidential pardon. There are proposals to penalise those who engage in homosexual behaviour in Zimbabwe's new Constitution (Radio Vop Zimbabwe 2010), a country which has historically used state power to restrict sexual rights and citizenship and denigrate homosexuality (Phillips 2004). Religiously encouraged laws such as these continue to create conflict between conservative religious institutions and secular groups. The second and more egregious situation relates to the proposed Bahati anti-homosexuality bill in Uganda first introduced in October 2009, discussed, but rejected in Parliament in May 2011. However, it could potentially be carried over into the next session of Parliament (International Gay and Lesbian Human Rights Commission 2011a, Kron 2011), which seeks to establish comprehensive legislation (ostensibly) to protect the traditional family by prohibiting any form of same-sex relations, allegedly spurred by the actions of US Evangelicals. This anti-homosexuality bill calls for imprisonment for those engaging in same-sex relations as well as for those members of the public who fail to report such activities, with the original draft calling for the possibility of life imprisonment and the death penalty by serial offenders or HIV-positive individuals (Civil Society Coalition on Human Rights and Constitutional Law 2009, Harris et al. 2010, NY Daily News 2010, International Gay and Lesbian Human Rights Commission 2011b). In a terribly sad turn of events, Mr. David Kato, a Ugandan gay-rights activist was beaten to death in his home on 26 January 2011, three weeks after he won a court case against a local newspaper that published the names and addresses of gay-rights campaigners in the East African nation (Bloomberg News 2011).

There is a tug of war in sub-Saharan Africa between those countries attempting to impose penalties on homosexuals and those countries, such as South Africa, Namibia and Botswana, eager to improve societal health by recognising the rights of homosexuals, especially as it relates to the fight against HIV/AIDS. Conservative Christian churches rely on literal interpretation of the Bible to deal with sin, which may allow them to separate themselves from the ‘pollution’ of the world. Liberal Christian churches focus on brotherly love and compassion. Christians pride themselves on doing things that Jesus Christ would do if He were here now, and many believe that Christ would condemn injury, let alone murder, based on sexual orientation. When church leaders in Tanzania were asked how they confront HIV/AIDS and its stigma, one pastor said, ‘If God is going to judge us on how we treated people with AIDS, we didn’t do very well. May God forgive us’ (Hartwig et al. 2006).

Gender

Religious institutions have historically been involved in the roles of men and women in society. Many conservative churches place women in dependent, submissive roles, justified by selected interpretation of biblical texts (Marshall and Taylor 2006). This conservative gender ideology impedes the control of HIV/AIDS when pervasive male hierarchical control is reflected in women having secondary status in society. HIV prevention messages that promote fidelity for a woman, regardless of a man's unfaithfulness, may effectively be a death sentence for women whose partners refuse to use condoms. Evangelical churches rely on a literal interpretation of ‘wives, submit yourselves unto your own husbands, as it is fit in the Lord’ to identify ‘appropriate’ gender-role expectations. For example, Agadjanian (2005, Agadjanian and Menjivar 2008) found differences in these standards and expectations for men and women in many churches in Mozambique. Condom use was likely to be discussed at men's meetings, but was unlikely to be discussed at women's meetings. Women congregants (especially those from healing churches) reported they were reminded that having an extramarital relationship could result in the loss of property rights and children. Women congregants had many traditional responsibilities, e.g. care for the sick, but were rarely allowed to assume pastoral leadership positions in African Evangelical churches.

Crumbley (2003) studied the attitudes toward women from three different churches in Nigeria. The Christ Apostolic Church prohibits women from being ordained. In the Celestial Church of Christ, women are not only prohibited from being ordained, but from entering the altar area or the church during menstruation. Although women in the Church of the Lord are prohibited from entering the church while menstruating and their participation in discussions of theological matters is limited since they are viewed as being ritually impure, they can be ordained but cannot perform Holy Communion, weddings, and baptism before they are menopausal or reach the age of 60.

In Malawi, responsibility for translating religious doctrine into practice is placed in the hands of men, effectively serving to control and subordinate women's work and sexuality. Not only do Malawian women receive fewer benefits than men from religious institutions, but they lack support from them (Rankin et al. 2005, p. 11). ‘If the man strays from the marriage, we say the wife should forgive him; if the woman strays, then the man should divorce her’. As with discrimination against sexual orientation, so the diminution of women at many levels in conservative religious institutions, although less recognised, is a serious obstacle to HIV prevention. Women are, in fact, too often seen as the vectors rather than the victims of HIV.

Opportunities and Challenges to Collaboration

Fostering problem-solving through critical consciousness (Freire 1970) and enhanced dialogue would help secular groups and Christian religious institutions join in implementing the four ‘human rights’ we have postulated as relevant to HIV prevention. It is as difficult for conservative religious institutions to consider changing their view of sexual and reproductive rights as it is for secular organisations to accept religious theology and doctrine. Neither religious absolutism nor secular free spirit will lead them to work harmoniously in reducing HIV/AIDS. Although the differences between conservative Christian institutions and the secular groups are too complex to be resolved in the short-term, we encourage both groups to begin by being clear where they are on the continuum between respect for religious doctrines and ‘human rights’. Interestingly, a Center for Health & Social Policy Report for the John D. and Catherine T. MacArthur Foundation and the Ford Foundation (Center for Health & Social Policy 2005) noted that only one secular organisation was working exclusively at the intersection of religion and sexual/reproductive health in Africa.

As to sexual autonomy, reproductive autonomy and tolerance of deviance, we recommend adopting Wingood's (2010) diplomatic approaches to congregants of religious organisations through organised church groups. This could take the form of meetings of small groups of women or families, guided by individuals who are neither religious nor secular leaders. These discussions should be constructive in helping to frame responses to these universal transgressions against the current conservative Christian ideals of sexual autonomy, reproductive autonomy, and tolerance of deviance.

While in religious terms sex outside of marriage is ‘sinful’, in the secular world it is often condemned as a personal betrayal with potential loss of property rights. In fact, the punishment, even when only social disgrace, may be more hurtful in secular groups than the price of forgiveness in religious groups. When considering sexual autonomy, both secularists and religious groups must remind themselves of the injunction of Jesus, ‘... he that is without sin among you, let him first cast a stone at her’ (John 8, King James Version, http://kingjbible.com/john/8.htm).

Secularists must devote themselves to convincing conservative religious institutions that many will not and cannot change their practices in reproductive autonomy. Individuals who have opted to have children outside marriage or fewer children in marriage could respectfully explain their decision to selected groups of congregants.

Stigma and discrimination are the most immutable of the four issues. Intolerance to social deviance of any kind is universal among secularists and religious congregants. Secularists must convince those conservative Christian religious institutions which consider homosexuality as socially or biologically deviant that acceptance or forgiveness is an appropriate Christian ideal. What is urgently needed is a dialogue that emphasises the convergence of religious institutions and secular groups to promote social justice, avowed by all.

Smith (2009) argues that even in the case of unfaithfulness to one's spouse/partner, God's righteousness and mercy make the use of condoms to prevent HIV a Christian ethical responsibility. Drawing upon the Protestant theology, Smith argues that religion and condoms for disease prevention are linked because of the Christian obligation to protect life. Revision by the Catholic Church of its ideological stance from no condom use to condoning condom use for disease prevention in limited circumstances is encouraging. As Winfield (2010) writes about Pope Benedict's stance on condoms, ‘condom use in some cases could be a first step toward a more moral and responsible human sexuality ... to diminish the risk of contagion’.

As promotion of condom use is the most effective method of reducing the spread of HIV, we propose that these parties concentrate on what seems achievable in the short-term:

• 1Selecting local people, e.g. tribal chiefs and political leaders who are experienced, to help plan and implement HIV prevention programmes and testing events.
• 2Encouraging people living or working with HIV/AIDS to serve as brokers between conservative religious institutions, liberal Christian institutions and secular organisations. By personalising HIV/AIDS, they can help all to become more accepting of condom use.
• 3Inspiring conservative religious leaders to provide HIV prevention messages, emphasising from the pulpit that God's righteousness and mercy, Christ's mission of forgiving, warrant appropriate condom use. It is an ethical responsibility for church leaders to teach that if church members cannot control their ‘sinful’ sexual activity, using condoms would dramatically reduce HIV risk.
• 4Mobilising liberal churches to discuss with conservative religious congregants their common religious responsibility to compel broader condom use. Teaming up liberal and conservative churches may be more acceptable than secular groups teamed with conservative churches because of trust and credibility within the commonality of religious organisations.
• 4Encouraging liberal Christian religious institutions and secular groups to join in discussions of condom use with conservative religious institutions in every available forum.
• 5Emboldening secular leaders to enhance their understanding of how the Bible relates to condom use, perhaps participating in bible studies at conservative Christian churches.
• 6Encouraging conservative Christian churches to hold discussions in which public health practitioners illustrate that condom use will reduce the number of sexually transmitted diseases as well as offspring from ‘sinful’ sexual relations.

In the longer-term, all of the above strategies should be employed to help integrate theology with ‘human rights’ relating to sexual autonomy, HIV/AIDS risk-reduction information, reproductive autonomy, as well as freedom from stigma and discrimination of sexual orientation and gender. Biomedical technologies that do not limit pregnancy -- antiretrovirals and medical male circumcision for HIV prevention -- may become more acceptable than condoms. Given steps like the Pope's tweaking of Christian theology as to condom use, we are optimistic that people of good will join together to reduce the spread of HIV.