Sub-Saharan Africa is presently being overwhelmed by the HIV/AIDS epidemic. Of the estimated 34 million world-wide infected with the virus, two-thirds of them live in the region. The countries of Southern Africa are particularly hard-hit, with prevalence of between 10-20% in Botswana, South Africa, Zimbabwe, Zambia and Malawi.[1] Health services, previously offering basic services on meagre budgets, are unable to cope with rising demands for care. Antiretroviral drugs have had a profound impact on life expectancy of those with HIV in wealthy countries and a decline in the transmission of HIV from mother to child. But such options remain a dream in countries where the entire annual health budget may only extend to the cost of providing one bandage and a course of antibiotics to each citizen.

Most governments in the region are heavily dependent on the voluntary sector to plug gaps in their HIV prevention and care programmes. Opportunities for churches to address the needs of local communities and national agendas have rarely been greater. Unfortunately, many churches have found themselves unable and unprepared to tackle the key issues, often because of discomfort at discussing sexual relationships and responding appropriately to those infected with the virus within the church. Recently, a meeting of 70 Malawian pastors admitted that they felt unsure of the facts about HIV and didn’t know what they should be saying to their congregations.

Medical students, doctors and nurses with HIV knowledge and skills have a valuable role to play in encouraging and equipping churches to face up to the needs and opportunities presented by this tragedy.

Raising HIV awareness

Even where information on the means of transmission of HIV and its progression to AIDS is readily available, misconceptions and myths continue to be perpetuated. Inevitably, sharing basic scientific knowledge on HIV/AIDS necessitates frank discussion on sexual behaviour and intimate anatomy that has previously been taboo in Christian environments. Most African languages do not have polite vocabulary for genitalia and sexual intercourse that is sufficiently explicit for the purpose. Most available educational material on HIV prevention puts an excessive emphasis on condom use and only cursory treatment of the importance of sexual abstinence outside of marriage and fidelity within marriage. Many churches are uncomfortable with condoms being given any role in HIV prevention strategies, seeing condom promotion as excusing sexual promiscuity. It is heartening that the ABC of HIV prevention introduced from Uganda into Southern Africa recently (Abstinence, Be Faithful, ‘Condomise’) presents an appropriate ranking. However, it is worth bearing in mind that many African women, even within the church, contract HIV in the course of being faithful to their husbands. The fact that they could have been protected from HIV by regular condom usage should be a warning against over-simplification of the prevention message.

Home-based care

The Good Samaritan is one of a number of examples in the Bible of people going out of their way to care for the sick. His action had practical, financial and social costs (Lk 10:33-35). Jesus commands us to provide for the needs of strangers, especially if they are poor, sick or in prison (Mt 25:35-36). The extent of the HIV epidemic is such that we must all be prepared to ‘be affected’ by the challenge of caring for those who are infected, regardless of the cost. Jesus risked his reputation by spending time with people who, in our times, are considered to be HIV ‘high-risk’ individuals. He found them to be more responsive to his message, but was misunderstood by the religious class (Lk 5:29-32).

As health services in resource-poor settings rationalise use of in-patient facilities, so the burden of caring for those with end-of-life illnesses is shouldered increasingly by family. Relatives are generally unprepared or supported for home-based care and there is great need for training, resources and support.

Examples of initiatives of churches in Southern Africa known to us include:

• Distribution of gift-packs containing essentials such as soap, gloves, plastic sheeting and a face-cloth to needy families in their community
• An HIV-carers support group offering support, training and exchange of ideas and experiences
• Foundation of hospice services offering in-patient and out-patient services, home-visits, child-care facilities and schooling
• Orphan care
• School HIV education teams

In responding to the needs of those with HIV in the community there are many opportunities for churches to work together sharing resources, skills and experience. Adequate preparation should include research of existing services by consultation with local healthcare providers, other churches, health consumer groups.HIV in the church In our experience it is unusual for churches to acknowledge and address issues arising from church members with HIV infection. We are well-placed to encourage other Christians to treat those infected with HIV with care and compassion. Fear of infection is a powerful stimulus to irrational and prejudicial behaviour. In addition, many Christians identify people with HIV as sinful individuals needing to repent of misdemeanours. At its extreme this can translate to an attitude that ‘true Christians don’t get HIV’. HIV infection may have been acquired in the course of rebellious behaviour against God, but prying into a person’s history is often a distraction from unconditional care, irrespective of past mistakes. Secrecy is the refuge most HIV-infected seek; sadly this perpetuates fear and ignorance of HIV, but few societies have successfully addressed the problem of stigmatisation towards those with HIV and confidences should be respected.

In Mosaic law the cost of adultery was death, but Jesus presented the sin of adultery in a new light that makes us all liable to judgement (Lv 20:10, Pr 5:3-5, Mt 5:27-28). We should be careful not to judge others as this will bring our own guilt under scrutiny (Mt 7: 1-2). When Jesus was called on to condemn the woman caught in adultery he treated her with compassion, but without compromising his call for her to repent. In doing so he challenged the selective, prejudicial, hypocritical and judgmental behaviour of religious people and ushered in the era of forgiveness and grace (Jn 8:1-11).

Churches have much lost ground to make up in creating an environment where all those infected and affected by HIV/AIDS are respected and not rejected. But it’s one thing for a church to pity and take a paternalistic approach; what is needed is for fellowships to recognise the value and gifting of a member of the body who has HIV. There are undoubtedly excellent pastors, Sunday school teachers and deacons known and unknown to be living with HIV.

Within the body of the church we all need each other. Those who are regarded as weaker, less honourable or presentable should, in fact, be treated with special honour and have their essential usefulness recognised and encouraged (1 Cor 12:20-27). Those members who have suffered and known God’s comfort through difficult experiences have the potential to provide care and comfort to others (2 Cor 1:3-7).

HIV and healing

God has all power over health and disease (Ex 15:26) and he has created natural medicines for our benefit (2 Ki 20:5-7). Healing was a major part of Jesus’ ministry. In healing the bleeding woman and the ten lepers we have examples of him dealing with people whose afflictions had made them social outcasts (Mt 8:1, 9:18). Jesus demonstrated that he had the power to heal the paralytic man’s physical disease, but, more significantly, the power and authority to forgive his sins. He also suggested that there was a connection between his spiritual and physical plight (Mk 2:1-11). On another occasion Jesus made it clear that it is wrong to assume that a disease is the consequence of an individual’s sin (Jn 9:1-3). The Church is instructed to conduct a ministry of prayer for healing. Confession and receiving forgiveness may be a necessary part of the healing process (Jas 5:14-16). Prayer should be in accordance with the level of faith of the persons praying and the one being prayed for. This means that prayers directed towards eradication of HIV from the body may be less common than prayers for relief of diarrhoea or breathlessness, energy to continue daily activities or peace for the future.

Pre-marital counselling

In Malawi medical students and young doctors are at risk of HIV infection. This is by virtue of their daily exposure to a predominantly HIV positive hospital population and seeking life partners from a population with an estimated HIV prevalence of 16%.1 At the Malawi Christian Medical and Dental Fellowship retreat in April 2000 a workshop addressed the issue of ‘HIV-testing prior to marriage’. The consensus was that couples contemplating marriage should be counselled on being tested together for HIV. This could be part of a church’s marriage preparation course, although ideally couples should be encouraged to be tested early in the dating process. Most participants stated that if they or their partner tested positive for HIV they would not proceed with marriage. All agreed that these issues should be explored prior to testing and that the risk of infection to potential children is an important consideration. The need for appropriately trained church counsellors was high-lighted as another area in which medical students and doctors can make a valuable contribution. In the case of one being found to be infected and both wishing to proceed with marriage there is information available based on discordant couple research.[2-4] Counselling should be offered in such situations on minimising the risk of infection of the non-infected partner by use of condoms and non-penetrative sexual activities, the risk of HIV transmission associated with having children and the implications for the non-infected individual of eventually caring for their terminally ill partner.

The extended family

If both test HIV-positive this has significant implications for the extended family, particularly if both fall sick concurrently. In most tribal customs in Malawi, in common with many other African traditions, ‘lobola’ is paid by a man to his wife’s family; this dowry means his wife becomes part of his family. The social and financial cost in the event of illness and death then fall heavily on the husband’s family who bear responsibility for both man and wife. As HIV takes its toll, particularly on the most productive, parental age-groups, the extended family system is failing to cope with a twelve-fold increase in the number of orphans during the past decade. The consequences have been an increase in street children, prostitution, malnutrition and other manifestations of social breakdown.

We are responsible for providing for the needs of our relatives (1 Tim 5:8), but the demands on those who may be the only wage-earners from an extended family or village ravaged by AIDS are immense. There is a precedent for the church identifying an area of need within the body (widows not being provided for) and responding with a practical structure and gifted people to take responsibility (Acts 6:1-6). Widows and orphans are special to God and should therefore receive particular attention from the church (1Tim 5:3-17; Jas 1:27). Churches in Malawi are developing programmes to assist families, enabling them to continue to care for their orphans.

Summary

The HIV epidemic is likely to dominate the future of most African nations for generations. The church in sub-Saharan Africa is suppressing an instinctive reluctance in favour of becoming a key role-player in prevention and care programmes. Medical students are well-placed to guide their church fellowships over some of the obstacles that hinder a confident, compassionate and creative response. A clear understanding of the roles and responsibilities of followers of Jesus should transform our attitudes and patterns of behaviour towards people infected with HIV. Those who live in regions of the world where the HIV prevalence is currently low have the luxury of more time in which to build a church community that is prepared to become affected by HIV for the sake of those who are infected. African Christians are acquiring a wealth of experience from which others can learn.