1In 2000 Robert Garner, a British anthropologist who became an AIDS activist, prefaced an article on the effect of religious affiliation on sexual behaviour in an AIDS-stricken South African township with the comment that the religious perspective was a “virtual foreigner” in the literature on AIDS (Garner, 2000: 41). In a review article on religion and HIV/AIDS policy Jill Olivier noted the longstanding “invisibility of religious organisations to the view of public health and policy makers”. It was only in the late 1990s that religious organisations, until then considered by healthcare professionals with suspicion if not hostility, started to be seen as partners in the fight against HIV/AIDS in an African continent notorious for its poor public health delivery (Olivier, 2011: 82). In 2001 UNAIDS made reference to religious organisations for the first time in its Global Strategy Framework and the following year the American government launched the President’s Emergency Fund for AIDS Relief (PEPFAR) which explicitly identified religious organisations as possible beneficiaries of public funding. In subsequent years, Olivier further observed, the desire to understand the role of faith-based organisations in health matters provoked a “flurry of research” sponsored not only by religious organisations but also by international health and development organisations such as UNICEF, WHO and the Bill and Melinda Gates Foundation (Olivier, 2011: 87).

3This paper, which builds on previous research on the history of HIV/AIDS and religion in sub-Saharan Africa (Denis, 2009; 2011), does not claim to be a systematic review of the literature in the field. There is simply too much to consider. It only aims to give an overview of the field. It starts with a quantitative analysis of the bibliographic data collected by CHART. In a second section the publications deemed to be the most significant during the past seven years are briefly described. It ends with a discussion of four leading themes of research in the field of HIV/AIDS and religion in sub-Saharan Africa.

Trends in research

5With this in mind we obtain a total of three hundred and seventy-six publications on HIV/AIDS and religion in Africa (in fact sub-Saharan Africa). Since the compilation of the CHART Online Bibliographic Database largely depends on indexes such as EBSCO or Web of Science with a few other publications randomly added, there is no doubt that the list is incomplete. The biggest gap concerns the literature in languages other than English. Among the three hundred and seventy-six publications considered here, only thirteen were not in English: eight in Dutch, three in French and two in German. A rapid survey using other sources of information revealed the existence of at least four French publications absent from the database (Fancello, 2007; Gomez-Perez, 2011; Tonda, 2007; Tourneux and Métangmo-Tatou, 2007). How big the gap exactly is, however, is difficult to establish. Another limitation of the CHART Online Bibliographic Database relates to academic dissertations. Only PhD and Masters theses from the United States and South Africa are indexed and even so some are missing (e.g. Kalofonos, 2008; Okyere-Manu, 2008; Joshua, 2011). One should also note that the “grey literature”, the non-peer-reviewed literature emanating from church bodies, NGOs or international agencies, is almost completely ignored. In some cases these publications contain useful research reports.

6These limitations notwithstanding, the CHART database is sufficiently furnished to give a broad idea of the research production on HIV/AIDS and religion in Africa during the past seven years. The first comment is that, during this period, sub-Saharan Africa has been a major focus in research on HIV/AIDS and religion. Roughly 40% of all entries concern this region, the rest being shared between publications of a general nature and texts on the United States (essentially the African-American community), Europe, Latin America and Asia.

Table 1: Publications indexed in the CHART Bibliographic Database (2007-2013)

7The literature on HIV/AIDS and religion in Northern Africa and the Middle East is almost non-existent. A second observation is that the number of publications on HIV/AIDS and religion tends to decrease from year to year in the period under review.

8An analysis of the geographical distribution of the publications on HIV/AIDS and religion in sub-Saharan Africa that are indexed in the CHART database (Table 2) shows the preponderance of research on eastern and southern Africa. The high number of publications on eastern Africa – both in the anthropological literature and in theological studies – reflects, as observed by the editors of a collection of essays, “the fact that research on the ramifications of the AIDS crisis has been going on for longer where this crisis is older and most acute” (Becker and Geissler, 2009: 2). Meanwhile, the table shows that South Africa has overtaken all the African other countries in quantitative terms. This is due to the intensity of the AIDS crisis in southern Africa, which has been the epicentre of the HIV/AIDS epidemic for two decades, to the quality of the research infrastructure and to the strong implantation of the Christian religion. The scarcity, apparent or not, of publications on HIV/AIDS and religion in central and western Africa is due to the under-indexing of publications in French. The only two countries from West Africa with a substantial number of publications, Nigeria and Ghana, use English as an official language. It is possible that more publications on HIV/AIDS and religion in countries like Senegal, Ivory Coast, Burkina Faso, Cameroon, DRC and Rwanda exist but they are not indexed in the CHART database. The same applies to the publications in Portuguese on HIV/AIDS and religion in Angola and Mozambique.

Table 2: Distribution of publications per sub-regions and countries

9The distribution of entries per genre shows a preponderance of peer-reviewed journal articles, which is hardly surprising given the tendency of public health specialists and social scientists to publish their work in that way. Against this background the presence in the database of twenty-seven books – more than three per year – and seventy-three chapters of books on HIV/AIDs and religion in Africa is significant. As noted earlier, the low figures for academic dissertations and grey literature are not significant given the fact that these categories of publications are difficult to index.

Table 3: Distribution of publications per genre

Journal articles	228
Books	27
Chapters of books	73
Academic dissertations	39
Grey literature	9
Total	376

Table 4: Distribution of publications per themes

Care (including orphan care)	47
Disclosure and stigma	22
Discourse and beliefs	16
FBO development	49
Gender	36
Healing	24
Homosexuality	2
Sexuality and prevention	61
Theology	83
Treatment (including ARV)	15
General	21
Total	376

10Lastly we should look at the distribution of publications per themes. This is a difficult exercise since, in many cases, the publications indexed in the CHART database deal with more than one theme. A certain element of appreciation was necessary. The figures only give a general idea of the aspects of HIV/AIDS discussed in the literature in relation to faith, religion and church life during the past seven years. It should be noted that only six publications deal specifically with Islam (with a few more dealing with Islam and Christianity). The majority focus on Christian doctrines, beliefs, rituals or attitudes. A small number (usually included in the category “Healing”) concern African traditional religion. Some deal with religion in Africa in general.

Social science and theology

12During the period under review ten publications on HIV/AIDS and religion in Africa – six collections of essays and four monographs – seem particularly significant. They belong to two fields of research – social science and theology – which encompass the same object but follow a different methodology and, more often than not, walk on parallel tracks without engaging with each other. We shall highlight the efforts made to combine the two approaches for a better understanding of the role of religion in the fight against HIV/AIDS.

13On the part of anthropologists of religion three collections of essays deserve particular mention. The first appeared, under the editorship of Felicitas Becker and P. Wenzel Geissler in one of the 2007 issues of the Journal for Religion in Africa. With twice as many contributions and a wider geographical scope – the original collection only focused on East Africa – a revised and expanded volume was published two years later as a book. In the introduction the editors stress that the authors do more than discussing the role – positive or negative – of religious institutions in prevention and care. This type of study, important as it is, had already been attempted. The book’s main contribution, they assert, is to examine “the way people rely on shared religious practice and notions of personal commitments in order to conceptualise, understand and thereby to act upon the epidemic, and on the suffering and loss that it brings about, so as to pursue life and creativity in spite of it” (Becker and Geissler, 2009: 2).

14The collection of essays published by Ruth Prince with Philippe Denis and Rijk van Dijk in Africa Today pursues a similar objective. It is to “explore and analyse the ways in which Christianity is becoming one of the most influential factors in the engagement of AIDs in some African countries” (Prince et al., 2009: v). Christianity, in other words, should not simply be seen as an ally, reliable or not, in the (biomedical) fight against HIV/AIDS but as a practice which shapes the manner in which people conduct their lives in the context of HIV/AIDS.

15The essays published by Hansjörg Dilger, Marian Burchardt and Rijk van Dijk in one of the 2010 issues of the African Journal of Research were first presented, like those published by Ruth Prince and her colleagues, at a conference organised by the IRNARA network. They use similar tools to approach religion with the difference that they include Islam and not only Christianity in their sphere of analysis and pay particular attention to the use of antiretroviral treatments in Africa. “Moving away from narrow interpretations that have informed much of the social sciences, in terms where medicalised and problem-oriented approaches were dominant,” the editors explain, “we notice a more explicit focus on HIV and AIDS as a lived reality, as a field of experiences and existential choices” (Dilger et al., 2010: 373). Significantly, the editors recognise the need for “agnostic and theological sciences” to find a common language to talk about matters of life and death in the context of AIDS, given the fact that “in many African societies people and institutions often express [these realities] in terms of faith” (ibid.).

16The book edited by Beverley Haddad contains the papers read by a group of researchers and activists from Africa and from Europe at a workshop organised by CHART in October 2008 in Durban. The purpose of the book is to present a status quaestionis of the research on the intersection between HIV and religion with particular emphasis on sub-Saharan Africa. The understanding behind the establishment of CHART as a network and the organisation of the workshop, Haddad writes in the introduction, is that “because religious institutions and beliefs system play both a positive and negative role in the impact of the epidemic, they must be drawn into collaboration with the other key role players” (Haddad, 2011: 3). It was recognised, she further observes, that the literature on HIV and religion “is written from two perspectives: religious studies and theology” (:4). Like the issue of the African AIDS Journal of AIDS Research on HIV/AIDs and religion referred to above, CHART’s book can be seen as an attempt to cross the divide between the two perspectives. It combines theological essays and papers informed by a Christian or Muslim perspective on biomedical or social aspects of the epidemic such as prevention, care, stigma or gender. In one of the chapters the South African theologian Steve de Gruchy gives a sober assessment of the state of theological reflection on HIV/AIDS. Much creative work has been done from the perspective of embodied theologies, African women’s theologies, gay theologies and feminist theologies, he notes, but surprisingly little theological reflection has been done on themes such as sin, salvation, redemption and liberation (de Gruchy, 2011: 188).

17From the milieu of Christian activists, theologians and ethicists comes another book on HIV/AIDS and religion, AIDS, 30 Years Down the Line... Faith-based Reflections about the Epidemic in Africa (Mombé, Orobator and Vella, 2012), which contains the papers read at a conference hosted by the African Jesuit AIDS Network (AJAN) in January 2012 in Nairobi. Nineteen of the thirty contributors are Jesuits, a sign of the importance recognised by the Society of Jesus to the HIV/AIDS epidemic in Africa. The book purports to give a snapshot of the “global conversation” among practitioners and scholars on the epidemic (Mombé et al., 2012: 31). Several authors emphasize the ethical dimension of the HIV/AIDS crisis with principles such as personal moral responsibility, social justice and common good in the forefront. The book documents the achievements and challenges of religious institutions in countries such as Kenya, Malawi, South Africa, Cameroon, Congo and Rwanda.

18Documenting or rather “mapping” the contribution of faith-inspired health care providers in sub-Saharan Africa is precisely the task which Jill Olivier and Quentin Wodon embrace in a three-volume book commissioned by the World Bank (Oliver and Wodon, 2012). While not being the main focus of the project, the contribution of religious institutions to HIV/AIDS prevention, care and treatment is discussed in several papers. The authors point out that the claim of “added value” and “comparative advantage” of faith-inspired health care providers is often made but rarely substantiated by evidence. Through various case studies the book examines whether they render a better service than public institutions and whether public-private partnerships are the way to go. It gives a nuanced picture of faith-based healthcare in sub-Saharan Africa with some institutions fulfilling their goals better than others.

19Three of the four monographs reviewed here deal with HIV/AIDS and religion in general terms. The fourth one highlights one aspect of the problem in one part of Africa but it does so in a manner which throws light on all religious institutions dealing with HIV treatment and care in Africa.

20The first monograph is authored by Elias Bongmba, a scholar of religion born in Cameroon who teaches in an American university. He approaches the theme of HIV/AIDS and religion from a theological point of view but with the willingness to take into account the biomedical, political, social and economic dimensions of the epidemic. An important characteristic of the book is its strong emphasis on gender. In line with the work of the Circle of Concerned African Women Theologians, a network of African women theologians active in several theological institutions in Africa, he insists on women’s vulnerability to the virus and the churches’ tendency to support patriarchal structures harmful to women in the face of the HIV/AIDS epidemic (Bongmba, 2007).

21In a book published three years later, Amy Patterson, a political scientist who also teaches in an American university, proposes a typology of church responses to the HIV/AIDS epidemic from early to late responders since 2000 and uses case studies to illustrate her model (Patterson, 2010). She takes into account issues such as HIV prevention messages, care and compassion, medical treatment, HIV testing before marriage and silence as well as the differences between Catholic, Protestant and Pentecostal traditions. She examines how these churches benefited from international programmes such as PEPFAR and the Global Fund to Fight AIDS, Tuberculosis and Malaria and how, in turn, they were instrumentalised by these programmes. Patterson’s typology has been criticised for over-simplifying certain church responses and for the manner in which she related the church types to the various stages of the epidemic. Yet, her book has the merit of providing an overview of the Christian responses to the epidemic in sub-Saharan Africa.

22With Jenny Trinitapoli and Alexander Weinreb’s book on Religion and AIDS in Africa (2012) we return to the anthropological perspective on religion and HIV/AIDS adopted by the three special issues of journals discussed above. Combining ethnographic work in Malawi and findings from studies conducted in other parts of Africa, they propose a comprehensive and, one may say, convincing analysis of the place of religion – Christianity and Islam essentially – in the day-to-day experience of the epidemic. They look at the manner in which religious beliefs and practices contribute to the way in which HIV/AIDS is understood, prevented and responded to in Africa. In a key section, while discussing at length the controversial issues of abstinence, faithfulness and condoms (the so-called ABC strategy), they go beyond the conventional war of words between biomedical professionals and defenders of religion by showing how, irrespective of what religious leaders say, people on the ground understand these three means of prevention – and others which most observers fail to notice. In another section Trinitapoli and Weinreb propose a response to the question, also raised by Olivier and Wodon in their three-volume collection of essays, of the effectiveness of religious institutions’ HIV/AIDS-related interventions. “Religion,” they note, “is central to AIDS mitigation in both symbolic and practical ways” (Trinitapoli and Weinreb, 2012: 184). Lastly, they discuss the issue of the effects of AIDS on religion. They observe that the congregations most actively engaged in providing support to people living with HIV and willing to pursue particular prevention approaches are the most likely to gain new members (:201). This would explain, at least in part, why the Pentecostal churches, whose dynamism in the HIV/AIDS field is well documented (Prince et al., 2009), continue to expand in Africa at the expense of the “mainline” churches.

23The fourth book reviewed here (Nguyen, 2010) does not discuss religion per se but its conclusions have a bearing on how religious institutions approach the reality of HIV/AIDS both at grassroots level and in relation to international organisations. A medical doctor with a sustained interest in anthropology, Vinh-Kim Nguyen spent six years, between 1994 and 2000, in Ivory Coast and Burkina Faso as a medical consultant, while collecting ethnographic data on local responses to the epidemic. What makes the book most interesting but also constitutes a limitation is its timeframe: it deals with the period of “triage” – or “rationing”, as other authors would say (Beyer and Oppenheimer, 2007: 216-19) – when only a handful of people in need of treatment received antiretroviral drugs during trial tests. The time of national ARV roll-outs had not yet come. In the late 1990s becoming a member of an AIDS-support group, participating in awareness campaigns and disclosing one’s status in public often constituted the best way of accessing the life-saving drugs. Borrowing from Michel Foucault the concepts of “technologies of the self” and “therapeutic citizenship”, Nguyen analyses the quasi-religious – and sometimes overtly religious – zeal of the AIDS activists he met in West Africa in the 1990s as part of a power game between well-funded international organisations, weak national public health systems, mushrooming NGOs and people living with HIV in search of treatment.

Research themes

24In the following pages four leading areas of research deemed are briefly described. The first three are at the intersection of anthropology of religion and public health studies; the fourth one deals more specifically with theology.

Religious affiliation as a predictor of HIV infection

25In the early years of the epidemic the opposition from some religious leaders to campaigns in favour of the use of condoms on the grounds that they would encourage promiscuity was met with hostility by medical professionals and public health experts. Today, more harmonious relations reign between the two groups of role-players. As Becker and Geissler note, “in medical and policy debates about HIV/AIDs, the place of religion is sometimes deceptively clear” (Becker and Geissler 2009: 5). In matters of prevention religious leaders are often more pragmatic that one may assume. Trinitapoli and Weinreb describe their position on condoms as an “unenthusiastic acceptance” (Trinitapoli and Weinreb, 2012: 107). And in any case it would be a mistake to assume that believers always follow the prescriptions of their faith-communities (Eriksson, 2011). Since Garner’s claim, on the basis of a sample which has been criticised for being too small, that the Pentecostal churches are the only religious body able to convince its adherents to reduce their level of premarital or extramarital sexual activity (Garner, 2000), the question of the effectiveness of faith-based prevention interventions has received a fair amount of scholarly attention (Denis, 2011, 62-65). Rachel and Robert Mash conclude their review of twelve papers on faith-based organisations and HIV prevention in Africa with the comment that, “in contrast with high-income countries [...] religiosity does not have a positive impact on sexual behaviour in Africa, apart from on the most committed. In general, church-based youth may be at higher risk than the general population since sexual activity is similar, but they are less likely to use protection” (Mash and Mash, 2013). Trinitapoli and Weinreb see faith-based prevention in a more positive light. Only approaches exclusively based on faith healing, they suggest, are problematic. “HIV prevalence is highest in churches that emphasize only faith healing and lowest in those that have no faith healing whatsoever, irrespective of whether they emphasize other approaches. In contrast, being in a community that combines regular messages about AIDS with openness to public health strategies (testing and condom use) provides the best protection” (Trinitapoli and Weinreb, 2012, 149-150).

Religion and public health

26HIV/AIDS gave religious institutions the opportunity to reposition themselves on the public health scene in Africa. In truth, Christian involvement in health matters has been high since the early days of the colonial era (Iliffe, 2006; Rasmussen and Richey, 193; Dimmock, Olivier and Wodon, 2012). But with HIV/AIDS faith-based initiatives in HIV and AIDS prevention, treatment and care, not forgetting the ever-expanding area of orphan care, have increased to an unprecedented degree. The huge expansion of funds for HIV/AIDS programmes following on the creation of the Global Fund for HIV/AIDS, Tuberculosis and Malaria, PEPFAR and other global projects in the early 2000s boosted the involvement of religious institutions in the fight against HIV/AIDS. A number of Christian healthcare institutions were selected by international organisations as funding conduits on account of their presence on the ground and their assumed reliability (Prince et al., 2009, vi). They contributed to the increasingly successful ARV roll-out programmes in sub-Saharan Africa (Munro, 2012; Rasmussen and Richey, 2012). Even though religious institutions benefited less from international funding that many people think (Olivier and Wodon, 2012b), it is undeniable that their visibility has increased (Prince et al., 2009: ix). This raises the question of the respective roles of international agencies, national states and religious institutions in the provision of healthcare in sub-Saharan Africa. By dealing directly with faith-based organisations these international bodies effectively bypass the national public health systems. This practice, which some authors describe as neoliberal, undermines the sovereignty of African states (Becker and Geissler, 2008: 15-17; Nguyen, 2012: 137-156). But this may change. There are signs that international agencies, the biggest provider of funding for ARV programmes in poor countries, are planning exit strategies. This may force religious institutions to create new forms of partnerships with national health programmes (Munro, 2012).

Treatment, care and the constitution of therapeutic communities

27If the effectiveness of religious institutions in HIV prevention sometimes appears problematic, their ability to mitigate the effects of the epidemic is undeniable despite the tendencies of some religious communities to stigmatise people living with HIV. There is, however, a “pronounced” difference between Christians and Muslims in matters of care and stigma which Trinitapoli and Weinreb attribute to the fact that, in Africa at least, the former tend to be more educated and more organised that the latter (Trinitapoli and Weinreb, 2012: 184-185). Perhaps because a strong ethos of care infuses most of the world’s religions, one tends to take for granted the involvement of religious institutions in treatment and care, in the form of faith-inspired primary healthcare facilities or of secondary care activities such as home-based care, support groups or orphan care. As Olivier and Clifford point it out, paradoxically this area is potentially the strongest in the religious sector but also the one about which we know the least (Olivier and Clifford, 2011: 368). In particular, the activities of the faith-based HIV/AIDS support group, some of which have become ARV adherence support groups, are not sufficiently documented. Nguyen’s detailed description of psychosocial support activities involving HIV positive people in need of antiretroviral treatment shows a disconnection between the generous intentions of the (mostly western) organisers and the daily struggles of participants having to survive in situations of deep poverty (Nguyen, 2010). But this is only one type of “therapeutic community”, as he terms the support groups he encountered in Ivory Coast and Burkina Faso, in a particular area and at a particular time. Attempts at exploring the social, religious and medical histories of groups of HIV positive people in other contexts, like Rasmussen and Richey’s work on HIV patients on ARV in Uganda (Rasmussen and Richey, 2013), are still rare. The challenge caused to a deeply entrenched religious culture by a drug of biomedical origin which saves lives and the manner in which it reconfigures the relationship between faith, science and modernity needs further exploration.

A “theology of HIV/AIDS”

Conclusion

29As the HIV/AIDS epidemic enters its fourth decade, there is a growing recognition that HIV/AIDS is far more than a biomedical phenomenon. It affects politics, culture, social relations, material life and also, of course, religion. This paper shows that the study of HIV/AIDS and religion, after a slow start, has shown a considerable development, not least in sub-Saharan Africa. The CHART Online Bibliographic Database, incomplete as it is, is testimony to the importance of this new field of research. The good news is that social scientists and theologians, after ignoring each other, show signs of being prepared to learn from each other. HIV/AIDS and religion exercise on each other a mutual influence. We understand better the role of religious beliefs and practices in shaping the lives of people affected or infected by HIV. But this is not a one-way movement. The epidemic also changes the institutional structures, the beliefs, the moral codes and the forms of sociability of religious people. Even if HIV/AIDS enters a new phase, with fewer infections and more people having access to treatment, these new forms of religious life are likely to remain for a long time.