AIDS prevention in Ghana

ARTICLE IN PRESS

Social Science & Medicine 61 (2005) 1689–1700 www.elsevier.com/locate/socscimed

From mandatory to voluntary testing: Balancing human rights, religious and cultural values, and HIV/AIDS prevention in Ghana Isaac N. Luginaaha, Emmanuel K. Yiridoeb,, Mary-Margaret Taabazuingc a Department of Geography, University of Western Ontario, London, Ont., Canada N6A 5C2 Department of Business and Social Sciences, Nova Scotia Agricultural College, Truro, Nova Scotia, Canada B2N 5E3 c Woodhull Medical and Mental Health Center, 760 Brooklyn Ave, Brooklyn, New York, USA

b

Available online 23 May 2005

Abstract This paper examines efforts by some churches in Ghana to reduce the spread of HIV/AIDS. The analysis is based on focus group discussions with two groups of men and two groups of women, along with in-depth interviews with 13 pastors and marriage counsellors in the churches studied. In response to government and public criticisms about human rights violations, churches that previously imposed mandatory HIV testing on members planning to marry now have voluntary testing programmes. However, the results suggest that what the churches refer to as voluntary testing may not be truly voluntary. Cultural values and traditional practices, including traditional courtship and marriage rites (which are performed before church weddings), not only clash with considerations about pre-marital HIV testing but also complicate the contentious issue of confidentiality of information on HIV testing. Associated with these complexities and issues of confidentiality is a reluctance among participants, particularly those from northern Ghana, to test for HIV. The results reveal how broader social impacts of HIV testing for those planning to marry may extend beyond individuals or couples in different cultural contexts. The findings also support the general view that there are no perfect or easy solutions to combating the HIV/AIDS pandemic. Practical solutions and programs for Ghana cannot be neutral to cultural values and need to be tailored for particular (ethnic) populations. r 2005 Elsevier Ltd. All rights reserved. Keywords: HIV/AIDS; Human rights; Religion; Counselling and testing; Marriage; Ghana

Introduction Despite growing knowledge of HIV/AIDS among people worldwide, documented indications of behaviour change, especially in countries with high prevalence rates, are limited. The Uganda ‘success story’ commonly discussed in the literature, is attributed in part to a Corresponding author. Tel.: +902 895 6699; fax: +902 897 0038. E-mail address: [email protected] (E.K. Yiridoe).

reduction in number of sex partners and casual sex, abstinence among unmarried youth (Stoneburner & Low-Beer, 2004), and increased condom use (AsiimweOkiror et al., 1997; Kilian et al., 1999; UNAIDS, 1998a). Similarly, in Zambia, Sohail (2002) reported a decline in casual sex among both women and men, and a modest increase in condom use. By comparison, Senegal has maintained a low, relatively stable HIV prevalence level partly due to an increase in condom use among sex workers, and a lower number of casual sexual partners compared to other West African countries (Meda et al.,

0277-9536/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2005.03.034

ARTICLE IN PRESS 1690

I.N. Luginaah et al. / Social Science & Medicine 61 (2005) 1689–1700

1999). In Ethiopia, Mekonnen et al. (2003) reported a decline in number of casual sex, sex with commercial sex workers, and genital discharge among male factory workers. For the most part, however, awareness about AIDS does not influence sexual decision-making or behaviour, and there is limited, if any, sexual behaviour change in other areas of sub-Saharan Africa (SSA) affected by the epidemic (Varga, 1997). For example, although SSA has more than 70% of all reported HIV/ AIDS cases in the world, it has the lowest level of contraceptive use, with West African countries in particular experiencing one of the lowest increases in contraceptive and condom use over time (United Nations, 1998). The persistent HIV/AIDS pandemic has resulted in a number of desperate measures in several countries. Despite the apparent consensus that mandatory HIV testing and related activities are infringements on human rights, health authorities and other organizations in several countries operate mandatory testing programs, mostly for pregnant women and prison populations (e.g., Danziger, 1996; Stone, 1998). Advocates argue that under certain conditions, mandatory testing, as well as other unorthodox measures to reduce the spread of HIV, may be justified. Hungary, for example, was strongly criticized for imposing mandatory testing on particular population groups during the early 1990s (Danziger, 1996). Yet, current low rates of HIV/AIDS in Hungary have been attributed, in part, to the initial ‘harsh’ measures that were implemented. Similarly, in the US, various states have implemented mandatory testing for prison populations (Stone, 1998). Furthermore, medical associations have endorsed mandatory pre-natal HIV testing, and all US states have included HIV testing in pre-natal care programmes, although expectant mothers can opt-out of the testing.1 The most recent and controversial endorsement came from the American Medical Association (2002) which ‘‘supports the position that there should be mandatory HIV testing of all pregnant women and newborns with counselling and recommendations for appropriate treatment’’. Other desperate or controversial measures aimed at curbing the spread of HIV/AIDS include virginity testing and subsequent monitoring in the Kwazulu Province of South Africa (Leclerc-Madlala, 2001), and suggestions to publicly announce the cause of death at the funeral of HIV/AIDS patients in Botswana (Fombad, 2001). In Ghana, the Gomoa District Assembly (2002) instituted an annual awards programme to honour 20 girls with proven virginity at the age of 19. Furthermore, a national ‘‘Miss Virgins HIV/AIDS’’ pageant was 1 See Eden (2001) for a detailed discussion of the issues surrounding the constitutionality of mandatory HIV testing of pregnant women in the United States.

organized as part of a country-wide HIV/AIDS prevention campaign, aimed at encouraging girls to stay as virgins until marriage (Ghanaweb, 2002). More recently, the situation has resulted in the establishment of virginity clubs in many parts of the country (Ghana News Agency, 2003; Ghanaian Times, 2002). A number of Protestant, Pentecostal and Evangelical churches, in their attempt to prevent the spread of HIV/AIDS among members of their congregations, also implemented mandatory HIV/AIDS testing for couples who were planning to marry. In response, international and national organizations, citing human rights law, continue to argue against such measures. The Ghana National Anti-AIDS Commission (GNAAC) strongly condemned the decision by Ghanaian churches to make HIV/AIDS testing mandatory (i.e., as a pre-requisite for marriage in such churches), arguing that such an action reinforces discrimination, creates fear and resistance, and is counter-productive to the aims of HIV/AIDS prevention and control (GNAAC, 2002). Consequently, these churches now claim to have changed to voluntary counselling and testing (VCT). Given the worsening trend of the pandemic, the above measures and other similar activities such as virginity testing will likely not disappear, even in the face of strong national and international condemnation. These developments call for a closer examination of how churches and other organizations are balancing human rights, religious and cultural values, and HIV/AIDS prevention in poor resource settings such as Ghana. As part of a larger research program on the role of the church in HIV/AIDS prevention and care in Ghana, this study reports the findings of a qualitative investigation which was conducted during May–June 2003, with four key objectives: (i) to explore the factors that led to the mandatory HIV/AIDS testing in some churches; (ii) to examine such churches’ perceptions of the human rights aspects of mandatory testing for HIV/AIDS, and voluntary testing and counselling; (iii) to examine regional differences in perceptions of HIV testing before marriage; and (iv) to assess how these churches handle the issue of confidentiality of information on HIV testing. This paper provides insight into an issue that not only generates great debate both in Ghana and internationally, but also arouses emotions among men and women, and among the younger and older generations. The paper contributes to the literature on how culture and traditions not only conflict with churches’ positions on pre-marital HIV/AIDS testing, but also on issues of confidentiality. In addition, the insights gained may be useful in designing HIV/AIDS prevention and care

ARTICLE IN PRESS I.N. Luginaah et al. / Social Science & Medicine 61 (2005) 1689–1700

programmes at the local level and improving health policy and health services delivery. Human rights and HIV/AIDS The conceptual framework for understanding the relationship between human rights and HIV/AIDS prevention and care is provided by international human rights law. International treaties which provide the framework on HIV/AIDS, human rights, and social issues include the Universal Declaration of Human Rights (1948), the International Covenant on Civil and Political Rights (1976), and the International Covenant on Economic, Social and Cultural Rights (1976). United Nations guidelines (see UNAIDS, 1998b) emphasize the importance of avoiding HIV prevention and care programmes that contain coercive or punitive measures, as such programmes are likely to reduce the participation of people living with HIV, and increase the risk of alienation of those at risk (UNAIDS, 2000). The purpose of the guidelines was to assist nations in translating international human rights norms into practical observance in the context of HIV/AIDS (UNAIDS, 1998b; Flanagan, 2001). The International Guidelines, referring to the Universal Declaration, argued that mandatory pre-marital testing for HIV/AIDS violates the rights of individuals (UNAIDS, 1998b). The International Covenant on Civil and Political Rights states that no one ‘‘shall be subjected to arbitrary or unlawful interference with his privacy’’. This right to privacy includes an obligation to seek informed consent for HIV testing, and an obligation to maintain the privacy and confidentiality of all HIVrelated information. Furthermore, mandatory HIV testing or registration, except for blood and/or organ donation, are inconsistent with this right to privacy. Besides the UN and its member organizations, other international communities have dismissed mandatory HIV testing for sexually active and other ‘high risk’ populations as counter-productive—helping to drive AIDS underground. For example, in the 1980s when Illinois enacted a law requiring mandatory HIV testing for all people applying for marriage licenses, approximately 40,000 people left Illinois and got married in other states during 2 years of the law’s existence (Endstad, 1989). People may refuse an HIV test because of fear of discrimination and a negative stigma attached to the disease. Invariably, while human rights law has to be interpreted and applied in diverse circumstances, perceptions and interpretation of the law in different cultures are complex and, in some cases, controversial (Freeman, 1998). Culture, the church and HIV/AIDS The various dimensions of culture distinguish one group of people from another (Ilcan, 2002; Appadurai,

1691

1996) and also serve as important lenses through which HIV prevention can be understood. Dimensions of culture (such as values, beliefs, and norms) are cultural constructs that influence marital and other sexual behaviours. Some analysts acknowledge that HIV transmission is a contextually bound social phenomenon and that beliefs about the various dimensions of culture are salient contextual factors in HIV prevention (Jemmott, Catan, Nyamathi, & Anastasia, 1995; Parker, 2001). In essence, such analysts assert that traditional and cultural values influence the knowledge and attitudes that affect HIV risk behaviours. Consequently, the beliefs and practices of particular African cultures, for example, have been seen as accelerating the spread of HIV/AIDS or at least hampering understanding and prevention of the epidemic in the region (Tobias, 2001). This has led some scientists to suggest that grounding HIV prevention programs in dimensions of a target group’s culture makes such programs understandable and more effective (Parker, 2001). However, in many African societies, a clear distinction between cultural, religious and secular life does not exist. The literature on the relationship between faith-based organizations and individual religiosity, and HIV/AIDS also provides several insights and background for our study. First, studies conducted mostly in western industrialized nations suggest that most religious leaders see HIV/AIDS as an important public health issue and recognize the need for HIV/AIDS-related education and support services to be provided, especially for their congregations (Elifson, Klein, & Sterk, 2003). On the other hand, African–American church leaders were early on criticized for not getting actively involved in HIV education and prevention (Robinson-Jacobs, 1998; Stolberg, 1998). Second, studies have acknowledged the potential role that churches could play in HIV/AIDS prevention efforts (e.g., Coyne-Beasley & Schoenbach, 2000). Indeed Van Ness (1999) reported evidence in support of arguments that religiously based social programs are more effective in some (US) populations than similar programs provided by government. Christian Century magazine, writing about the AIDS epidemic in Africa, put it more bluntly when it noted that ‘‘any real dent in the AIDS epidemic cannot be made without the help of African churches’’ (Christian Century, 2000). The potential positive impacts or ways in which religious beliefs and behaviour and faith-based organizations can promote human health in general, and the spread of HIV/AIDS in particular, are in terms of: (i) the role of religious practices and behaviour in influencing personal health and safety; and (ii) the impact of social ministries on community and social health (Van Ness, 1999). Garner (2000) noted that, based on ideological underpinnings such as indoctrination, subjective experience, exclusion and socialization, different

ARTICLE IN PRESS 1692

I.N. Luginaah et al. / Social Science & Medicine 61 (2005) 1689–1700

churches manifest varying (extensive and intensive) powers that can affect the behaviour patterns of their members. Churches with extensive power (e.g., the Roman Catholic Church) can organize large numbers of people, potentially across large territories and national borders, but may compromise on member commitment. In contrast, those with intensive power (e.g., Pentecostal churches) can mobilize a high level of commitment from participants. There are contrasting reports about the role of religion on sexual behaviour and HIV/AIDS in Africa. For example, in a study on the relationship between religion and contraceptive use, Addai (1999) found religion to be a significant predictor of contraceptive use, with women who belonged to liberal religious groups more likely to use contraception than women from conservative religious groups. By comparison, Lagarde et al. (2000) reported that Senegalese who considered religion as very important were less likely to report intention to be or actually having been faithful in protecting themselves from AIDS. Such individuals were also less likely to feel at risk of getting HIV. Ghana as a whole has experienced a resurgence in Christian religious activities, especially during the last few decades (Takyi, 2003; Woodward, 2001). In a millennium survey involving 60 countries, Gallup International (2000) reported that 98% of Ghanaian respondents belonged to a religious denomination. Among these, 82% reported having attended church regularly. Christian organizations in the country range from mainstream traditional Christian denominations (i.e., established orthodox churches such as Roman Catholicism), a collection of groups that include African syncretic, faith healing organizations, to charismatic, evangelical and, Pentecostal churches (Nukunya, 1992; Assimeng, 1989). Pentecostal churches are increasing in popularity, partly because of their manifestation of ‘intensive’ power, and their appeal to the needs of an impoverished population dissatisfied with existing socioeconomic conditions (Nukunya, 1992; Takyi & Addai, 2002). The above review provides the backdrop for examining how churches are balancing human rights, religious and cultural values in HIV/AIDS prevention efforts.

unknown themes to emerge, and allow for interviewer responsiveness. The characteristics of the sample studied are summarized in Table 1. IDIs were conducted with Pastors (n ¼ 6), and marriage counsellors (n ¼ 7), using face-to-face conversations, semi-structured by a checklist of topics related to the research objectives. Dialogues during the IDIs helped go beyond expressed concerns to understanding deeper issues, such as why the churches changed from mandatory testing to VCT and how churches handle confidential information related to HIV testing. This method of inquiry allows the meanings attached to HIV/ AIDS prevention strategies to be understood within a socio-cultural context and in the context of people’s everyday life. The IDIs were followed with FGDs with church members. A total of four FGDs were organized separately for men (i.e., two groups of n ¼ 8 þ 8), and women (i.e., two groups of n ¼ 8 þ 7), to achieve maximum diversity in opinions and reduce domination of the discussions by a particular gender group. The participants were recruited through a snowball sampling strategy, with initial contacts established through the Pastors, marriage counsellors and church elders. All the participants were from Pentecostal churches. Given the small sample studied and the method of sampling, caution should be exercised in interpreting the results from the study. In contrast to IDIs which highlight the views and attitudes of single individuals, focus groups reveal how particular individuals’ opinions are accommodated or assimilated within an evolving group process (Kidd & Parshall, 2000). Kitzinger (1995) noted that focus groups are particularly appropriate for facilitating discussions on sensitive topics because the less inhibited members of the group often break the ice for more shy or emotional participants. This was relevant for this study where a range of cultural issues could have hindered people discussing issues related not only to sexual matters but also to HIV/AIDS. However, the context in which the FGDs were held (i.e., among church members and with a view to helping to address a serious public health problem) provided some assurance and confidence needed for an open discussion. Although documenting FGD interaction can be a useful component of FGD data, capturing this interaction was beyond the scope of this study.

Methods The research instruments—IDI and FGD checklists Qualitative research methods involving both in-depth interviews (IDIs) and focus group discussions (FGDs) were used for this study as contextual information was required in order to achieve the research objectives. Such research methods can allow for exploring how and why people feel about HIV/AIDS testing, provide an opportunity for understanding the context of beliefs about HIV/AIDS, develop a setting for previously

We developed separate checklists for the IDIs and FGDs, with a primary focus on using the information to address the four research objectives. Each checklist contained topics related to knowledge of HIV/AIDS, human rights and mandatory testing, VCT, regional differences in perceptions about testing for HIV/AIDS, the impact of the church on HIV/AIDS prevention, and

ARTICLE IN PRESS I.N. Luginaah et al. / Social Science & Medicine 61 (2005) 1689–1700

1693

Table 1 Characteristics of study participants Characteristic

(a) Northern Ghana In-depth interviews

Participants

Sex

Age

Number of children

Marital status

Pastors

M M M M F M M (n ¼ 8) F (n ¼ 7)

42 50 41 40 38 39 — —

4 5 5 3 2 4 — —

Married Married Married Married Married Married Mixeda Mixed

M M F M M F F M (n ¼ 8) F (n ¼ 8)

35 50 44 47 35 41 39 — —

2 5 3 5 2 4 4 — —

Married Married Married Married Married Married Married Mixed Mixed

Marriage counsellors

Focus group discussions (b) Southern Ghana In-depth interviews

Pastors

Marriage counsellors

Focus group discussions a

Focus group participants were either single and planning to marry, or married.

issues of confidentiality. Each checklist went through several stages of review and revision by the researchers for clarity, flow and length. In addition, the checklists were designed to be flexible so as to allow the interviewer to follow up on issues raised by participants that were not initially anticipated. To maintain consistency, all IDIs and FGDs were conducted by the same researcher. All discussions were tape-recorded and transcribed verbatim in two native languages (i.e., Dagaare and Twi), as appropriate, in order to accurately represent respondents’ views and were later translated into English. Analysis The data from both IDIs and FGDs were given equal importance, and the analysis was guided by the key themes that were derived based on our research objectives, questions in the checklists, and the literature on human rights, religion and HIV/AIDS. Under each theme, we created categories of responses to the questions that were asked prior to line-by-line coding, a coding method which is generally considered the most appropriate (Strauss & Cobin, 1990). For example, under the theme ‘‘Mandatory HIV Testing for Couples Planning to Marry in Church’’ we developed key categories on reasons for and against mandatory testing before marriage.

The key categories under each theme were reviewed several times in order to ensure that concepts pertaining to the same phenomena were coded in the same category. We also took a number of steps to ensure a consistent analysis of the data (see Patton, 1987), including the use of a topic list. Two investigators independently coded portions of the transcripts and compared and discussed discrepancies in the coding process. Furthermore, because the transcripts were translated from Dagaare and Twi into English, we used member checking as a technique to ensure validity of the results. This was done a week after the data collection and translation. In order to reduce misrepresentation, participants were asked whether the translation reflected what they had meant in the discussions (see, Krefting, 1991). In analyzing the data we were interested in establishing broad areas of consensus and differences between the church leaders (pastors and marriage counsellors) and church members on various topics related to HIV testing. Direct quotations from the transcripts of the IDIs and FGDs illustrate the themes and also serve to contextualize responses from the study participants. The participant’s sex (M ¼ Male, F ¼ Female) and primary role in the church (i.e., P ¼ Pastor, MC ¼ Marriage Counsellor, CM ¼ Church Member) are provided at the end of each quotation, as appropriate. To maintain anonymity of the Pastors and marriage counsellors

ARTICLE IN PRESS 1694

I.N. Luginaah et al. / Social Science & Medicine 61 (2005) 1689–1700

interviewed, the location (i.e., N ¼ Northern Ghana, S ¼ Southern Ghana) is not provided at the end of quotations.

Results The findings are organized in line with the study objectives and the themes that emerged from the analysis: mandatory HIV testing for couples planning to marry in Church, change from mandatory testing to VCT, comparison of perceptions about HIV testing between regions, and issues of confidentiality. The theme on whether voluntary testing is truly voluntary is the only theme that was not initially anticipated during the FGDs and IDIs. Mandatory HIV testing for couples planning to marry in church In Ghana, individuals can go for HIV testing in hospitals or in privately operated medical laboratories. If the request comes from an individual (as opposed to a physician), the written medical test results are given to such a person. However, such individual, voluntary initiatives are rare. Participants in the study indicated that when an HIV test is requested by a couple planning to marry in a church, the test results are usually given to the couple who, in turn, present the test results to the Senior Pastor-in-Charge. The Senior Pastor then discusses the implications of the results with the couple as part of the church’s marriage preparation and counselling process. Discussions about why mandatory testing was imposed on prospective marriage partners evoked many emotions and feelings of sympathy among some participants. There was a general consensus that a sincere desire to prevent innocent brides and grooms from contracting the deadly virus was the main motivation for imposing mandatory testing on church members. As indicated by the following comments, participants agreed that the whole notion of mandatory HIV testing evolved when the churches realized the HIV/AIDS pandemic was showing no indications of improvement. We had an HIV/AIDS awareness programme in our churchy After an expert delivered a lecture, we were shocked at the numbers, ywe were told that the disease is fast spreading in Ghana, and that about 200 people contract the disease dailyythe immediate feeling was that we were all at risk and that something must be doney we decided all those who are planning to marry must be tested for HIV/ AIDSy We wanted to protect our future generationsy(M, P)

One participant indicated that, in their church, the decision to impose mandatory testing on those who wanted to marry, was simple and unanimous: ‘‘no medical certificate, no marriage in the church’’. The key issue was that ‘‘those who are not avoiding pre-marital sex, and who may be HIV-positive should not spread the disease to those who are HIV-negative’’. By requiring testing for HIV/AIDS before marriage, Church leaders (most of who have been against the use of condoms) indirectly express their view that abstinence is the most effective HIV prevention method. Pastors and marriage counsellors generally disagreed that mandatory testing would embarrass or stigmatize certain individuals or groups. We are a family in the house of Godyeach of us is his/her brother’s or sister’s keeperynobody will go out of his/her way to plan something with the aim of embarrassing other members of the churchywe did not know who may test HIV-positive or negativey (F, S, CM) Some people say that mandatory testing will isolate certain groups and stigmatize other peopleyShould we adopt a do nothing approach? Should we sit down and watch as the pandemic devastate us? yBy letting members know they are required to bring a clean HIV/AIDS medical report before marriage, it puts the onus on them to stay clean or at least think about their potential partnersy we are trying to save some innocent men and womeny (M, MC) By invoking religious arguments in support of mandatory HIV testing, some participants disagreed with the view that mandatory testing might send people underground. One respondent indicated: If you are a true Christian and fearful of your Godywhy would you be afraidywhy would you go undergroundyif any members quit the church or go underground because of the fear of HIV/AIDS testing, these members may actually be the true wolves in sheep’s clothesyhow can we worship with and trust such peopley (F, S, CM) The overall perception among respondents was that ‘‘mandatory testing was the right thing to do, considering the rate of spread of the epidemic,’’ and with no cure or end in sight. Participants in both IDIs and FGDs were therefore surprised that the GNAAC is against mandatory testing because it violates the rights of potential couples. One participant indicated that: ythey [i.e., the National Anti-Aids Commission] told us to stop mandatory testing because it is against human rights laws to use coercion in anyway to get anyone to test for HIV/AIDSythey said HIV/AIDS testing should not be made compulsory for anyone. (M, P)

ARTICLE IN PRESS I.N. Luginaah et al. / Social Science & Medicine 61 (2005) 1689–1700

Besides human rights issues, participants noted other reasons against mandatory testing, including the view that ‘‘mandatory testing can create a false sense of security, especially among people who may use it as an excuse for not following more effective measures for protecting themselves and others from infection’’. The response of the churches is probably captured more succinctly by one respondent who noted that ‘‘to avoid any confrontation with these politicians, we agreed to make the testing for HIV before marriage voluntary’’. From mandatory testing to voluntary counselling and testing We examined respondents’ perceptions of the issues arising from the churches’ move from demanding mandatory HIV testing from members who were planning to marry to encouraging members to go for VCT. Overall, participants were of the view that the VCT programs for potential couples were useful and going well.

1695

that we need more training and government support to be able to handle such complex situationsy (F, MC) Marriage counsellors who were involved in pre-HIV test counselling, identified denial as one of the most problematic barriers to their HIV/AIDS prevention efforts. One participant indicated that: Most of the young people usually perceive themselves not to be at risky. Potential marriage couples may also recognize personal risk, but not appreciate the risk derived from high-risk behaviour of a partnery they always seem to trust the other partnerymostly they say their partner is not like that [i.e., having multiple sexual partners]y (M, MC)

The voluntary testing program has been going on well: So far, all the couples we have wedded in the last 2 years or so have done the testywe thank God that we have not yet confronted a situation where a member has tested HIV positive. (M, P)

It was revealed that although a church will pay for the cost of an HIV test as part of the church’s VCT and marriage preparation programme, prospective couples typically pay for the test by themselves (i.e., separate from the free VCT offered by the church). While concerns with the cost of HIV testing never came up in discussions with participants from the south, participants from northern Ghana noted the high cost involved,2 as well as other resource limitations that hamper going for HIV testing before marriage. One participant indicated:

While the above comment seems to suggest that those who are members of a church or who readily volunteer to go for testing are likely to be the ones of ‘‘good behaviour and HIV negative’’, this has not always been the case, as some churches have reported HIV positive cases involving people who were planning to marry. One participant reported that:

In our society, poverty is so severe, many people can not even raise the money to dowry their wives, let alone going for expensive HIV testingy I hear the cost of HIV testing is about 400,000 Cedis [or approximately $40US]y Who can raise this kind of moneyy For most of us, it is a huge problemy(F, N, CM)

On one occasion, we had to deal with a situation where the groom went for the test and the results came back positivey He went back for a confirmatory test and the results again came back HIV positivey With our ultimate goal being to protect those who are not yet infected, we did not recommend the marriage to go aheadywe counselled the couple, and the marriage did not go aheady (M, P)

Meanwhile, the Churches still expect those planning to marry to go for VCT. As a result of this expectation, some participants wondered whether what is now being referred to as voluntary testing and counselling is really truly voluntary. Voluntary testing and counselling is not truly voluntary

Many of the marriage counsellors indicated that they had not encountered the problem of having to counsel an HIV positive individual. The few who did noted difficulties they faced as a result of insufficient technical knowledge and lack of government assistance. One participant said:

The Churches’ demands for HIV testing were discussed extensively in both the IDIs and FGDs, with different views emerging from pastors and marriage counsellors compared to other church members. Stressing the voluntary nature of the process, one pastor indicated that ‘‘the church will perform a marriage without an HIV/AIDS certificate, but of course, we

As a marriage counsellor, I did the best I could when I had to counsel one of our members who was diagnosed with HIV through the voluntary testing programy For me, it was a difficult situation, and I did what I couldybut that left me with the feeling

2 The cost of an HIV test across Africa ranges from $12 to $24US (USAID, 2000). However, the current daily minimum wage in Ghana ($US1.00 ¼ 8600 Cedis), for example, is approx $1.07US. This makes HIV testing quite expensive in the context of our study area.

ARTICLE IN PRESS 1696

I.N. Luginaah et al. / Social Science & Medicine 61 (2005) 1689–1700

strongly encourage our members to go for the test’’. However, some participants in the FGDs thought otherwise, and argued that the programs by the churches may not be truly voluntary. One participant indicated: In our church, we are told it is voluntary, yet everybody who wants to marry is expected to bring the HIV test resultsyit is not truly voluntaryyeverybody planning to marry feels compelled to go for the test to please the churchy (M, S, CM) As with other respondents, younger participants in the FGDs talked about the intimidating nature of the process. Some of those who did get an HIV test before church marriage indicated that they agreed to the test because they thought that refusal would have compromised their relationship with church elders and other members:

Regional differences in perceptions of HIV testing Several participants from southern Ghana were more positive about HIV testing before marriage, with those who were preparing to marry more willing to go for an HIV test. By comparison, this was not the case with participants from northern Ghana. Besides concerns with the cost of the HIV test alluded to earlier, the following comments from participants from northern Ghana highlight how HIV testing, be it mandatory or voluntary, comes head to head with deep-seated cultural practices and may threaten long-lasting exogamous relationships.

Yes, they told us it is voluntary, but that we were strongly encouraged to go for the testythere is always the feeling that one has no choice about taking the testywhat will the others think of you if you say you don’t want to do the testythis is the same as saying you will no longer come to churchy(M, S, CM)

In our area, it is difficult to demand HIV testing before church marriage. Our culture is built on longlasting relationships and reciprocityy if you go and tell a family that you want their son or daughter to go for HIV test before he or she can marry your son or daughter, they will simply tell you to go away and never come backythey are going to say you do not trust their son or daughterythat you do not trust or respect their familyy and there will be no marriageyIt is difficult, and many people will not go for HIV testingy.(F, MC)

Invariably, these churches did not put anything in place in anticipation of positive test results, beyond advising potential couples not to go ahead with a marriage.

A younger participant agreed with the above view and also noted some of the difficulties and psychological implications of demanding HIV testing from a potential husband or wife.

We must have been naı¨ vey maybe we asked our members to go for testing, thinking that nobody will ever return with HIV positive resultsywe were not prepared for the worseywhen we had the first case. We [church leadership] are scrambling to put in place measures beyond telling the couple not to get marriedy(F, P)

Once you are contemplating HIV test, this simply means there is no trust between the two of you. Unless you did not know each other, why would you be suspicious of your potential husband or wife, and demanding an HIV test from them? For me, it is a big problem. (M, N, CM)

Overall, female participants were of the view that the whole process of VCT seems biased against women, as noted by one participant: yall the focus is usually placed on the test results of the bridey while the men are reluctanty there seems to be the feeling that if the women test negative then everything is finey Another female participant’s comment summarized how they view the perceptions of males, when she noted that ‘‘y the view is that women get infected easily, and more women have the disease as compared to men, so we are obviously the ones everyone is worried abouty’’ The churches’ efforts at encouraging VCT come faceto-face with regional and cultural issues that have implications not only for the churches’ role and efforts, but also for HIV/AIDS prevention and care programmes in general.

In general, marriage in Northern Ghana is between families and usually involves traditional courtship and dowry rites. Among Christians, this must precede a wedding in a church. Culturally, while teenage and premarital sexual relationships are not acceptable, completion of the traditional marriage and dowry process does not forbid sexual relationships that may precede a church wedding. This implies that by the time a couple begins the church process and requirements (e.g., HIV testing) towards a wedding, they are already legally married—in the traditional sense. One participant observed that: After you have dowried your wife, you cannot go back and tell your in-laws that I am bringing her back because she has tested HIV positive. In any case, if she is HIV positive, you might have already been infectedy The process of marriage in our culture makes pre-marital screening complicatedy(M, N, CM)

ARTICLE IN PRESS I.N. Luginaah et al. / Social Science & Medicine 61 (2005) 1689–1700

This complication of traditionally getting the consent of a partner for marriage before a formal church wedding is not unique to the north alone. However, urbanization and its attendant debasement of traditional customary requirements and values in southern Ghana have, over the years, reduced the difficulties and complications in that region. Consequently, couples tend to know each other better and, in particular, are in a position to take some marriage decisions without undue involvement of family members. Participants from northern Ghana noted that current efforts around HIV/AIDS prevention and care are concentrated in the urban centres, and they expressed the need for more HIV/AIDS education and prevention programs in rural communities. We have a lot of difficultiesy What we need here [Northern Ghana] is more educational campaigns from village to village, to let the people understand what is heading our wayyMost people still don’t wake up worrying about HIV/AIDS, and it is difficult to present this at the family levelyAgain, the old relationships and trust that have been built over several hundred years are difficult to dismantleywe need to do more at the village level. (M, N, CM) Emerging from this is the complex issue of confidentiality of HIV information. The issue of confidentiality The following comment from a respondent illustrates how the churches try to protect the confidentiality of those who go for the test, especially in instances when the test results come back HIV positive. We make sure that all prospective couples planning to marry, and who are willing to do the test, do so before the church officially announces their intention to marryythe aim is to avoid publicizing the marriage and later cancelling the wedding as this will raise suspicion among the congregationywe continuously encourage potential partners to take this first step before going public with their plansy(M, P) Consistent with the notion of shared confidentiality, when information about a person’s HIV status has to be shared with others (e.g., the family of the groom or bride-to-be) who are involved in that person’s case, confidentiality is necessarily compromised. One participant indicated: ythere is simply no indication of how far sharing of information must go when you are dealing with individuals and their familiesyyou cannot tell the groom or bride anything and ask them not to tell

1697

their families when in fact the whole process of marriage was initiated at the family levelyit is complicated and difficultybut we are determined not to let concerns with confidentiality destroy some innocent members of our churchy(M, P) In summary, this study reveals a willingness of churches and their congregations to tackle the HIV/ AIDS pandemic in ways that may not necessarily be aligned with international human rights law. In addition, the results reveal challenges such as the cost of VCT, perception of church members that VCT is not truly voluntary, lack of professional counsellors, issues of confidentiality, and how deep-seated cultural issues may conflict with HIV/AIDS prevention efforts. This highlights the need for careful consideration of such issues and their integration into HIV/AIDS prevention programs such as VCT.

Discussion and conclusions The findings in this study highlight how Pentecostal churches in Ghana are making efforts to prevent the spread of HIV/AIDS among their membership. In the earlier stages of the HIV/AIDS pandemic in SSA, the church and the state collided on such issues as the use of condoms. In the present situation, it is ironic that the clash is on human rights, whereby the state is demanding that churches discontinue mandatory HIV testing before marriage. The church leaders argue that their actions were motivated by the reality of the HIV/AIDS pandemic and their belief that they are genuinely trying to protect those who are HIV negative from becoming infected. The pastors also argue that HIV testing will enable people to alleviate uncertainty about their HIV status. Despite the controversy, their initial requirement of ‘no medical certificate, no marriage’ draws parallel to the ‘zero grazing’ policy (see Stoneburner & Low-Beer, 2004), which contributed to a decline in HIV infection rate in Uganda, and the mandatory testing for venereal diseases prior to issuing marriage licenses in some US states (Georgia Division of Public Health (2003). Following the criticism by the GNAAC, the churches claim they have resorted to encouraging their members to go for VCT before marriage. In addition, there is the belief that VCT services can facilitate behaviour change, as those who are HIV negative may subsequently resort to condom use in order to remain so (see Worthington, 1997). The subtle, coercive, element, whereby church members feel compelled to go for VCT, may stem from the social context of these Pentecostal churches, which are characterized by indoctrination and wielding of intensive power of influence over their members. It is important to note that, although the churches’ efforts are useful, they must be viewed within the context

ARTICLE IN PRESS 1698

I.N. Luginaah et al. / Social Science & Medicine 61 (2005) 1689–1700

of recent reported sexual scandals in some churches (e.g., the Catholic Church in the USA), which have dented their moral authority and respect, and could influence the way people respond to church HIV prevention messages (such as abstinence from premarital sex). This study also revealed the complex relationship between the traditional marriage process and the churches’ expectation of abstinence from sexual relationships before marrying in the church. It also raises the question of the churches’ centrality in the context of partner selection and marriage ceremony in both Northern and Southern Ghana, and the effectiveness of their HIV prevention strategy. In this context, persistent gender inequalities, socio-cultural norms, together with the position of some churches on issues such as condom use, continue to make it difficult for women to negotiate safer sex practices. Yet there is an implicit focus on the test results of women since they are perceived as more vulnerable. The apparent focus on women does not only betray the aim of the process, but could also create a false impression among men regarding risks of HIV infection. Consistent with other studies (e.g., Fombad, 2001), confidentiality emerged in this study as an important problem, not only for those directly affected, but also for extended family and community members. While those who are infected with the HIV/AIDS virus certainly have the right to privacy and protection of the confidentiality of their status, others, especially their potential bride or bridegroom, have a right to be protected from infection by such persons. The dilemma then is, when families—and, in some cases, entire clans—are involved in the marital process, as is the case in Northern Ghana, to what degree should respect of the autonomy of the individual, one’s right to privacy and confidentiality of one’s medical condition, be allowed to stand in the way of the need to inform others, thereby helping to reduce the risk of spreading the virus? There is a danger that without assurance of confidentiality, young people planning to wed in a church may hesitate to go for testing and counselling, fearful of the repercussions that unauthorized disclosure of their status to family members and the public will have on their lives. On the other hand, nondisclosure of HIV positive status, especially to a traditional legal wife, prospective spouse and any (previous) sexual partners, will make individuals vulnerable to infecting others and defeat the church’s HIV prevention efforts. Clearly, it will be vital to improve protection of confidentiality and, at the same time, to take all possible steps to reduce stigmatization and discrimination against those who test HIV positive. Local churches and other religious groups may be well placed to act as catalysts to effect change in behaviour in order to help prevent the spread of HIV. However,

religious groups considering implementing programmes such as VCT before marriage, need to recognize the local and cultural issues that may deter people from going for VCT. For example, in northern Ghana where people appear to be embedded in tradition and culture with regards to marriage, change can only come through customized efforts involving widespread and intensive awareness campaigns at the local level. Such education must target both the young and the elderly, especially in rural areas where the elderly still have a significant role in marital issues, with a tendency to preserve their customs and culture, and exogamous relationships. In addition, it is important for such educational and awareness initiatives to be promoted using local languages and dialects in order to increase access to information on VCT and HIV prevention in general, and also to cover topics on the importance of VCT testing before marriage, be it traditional or in the church. Furthermore, health care administrators need to work cooperatively with traditional leaders and chiefs to encourage and promote HIV testing before completion of the traditional marriage process (which usually culminates with the acceptance of the dowry by the bride’s family). Programmes to address issues surrounding the stigma that may result if individuals test HIV positive are clearly very important. Furthermore, given that there are few counsellors for HIV in Ghana as a whole, customized training of more professional counsellors, especially training that is relevant to rural communities, can help break the barriers to VCT. As the HIV pandemic continues to worsen, the rate at which various desperate measures (such as establishment of virginity clubs and ‘‘Miss Virgin’’ pageants) are currently expanding in Ghana will likely continue to raise questions about the clash between human rights and HIV/AIDS prevention.

Acknowledgements We wish to thank the pastors, church leaders, marriage counsellors and all the people who participated in this research. Special thanks to Dr. Suzan Ilcan, of the University of Windsor, for helpful comments on an earlier draft of this paper. We would also like to thank the anonymous journal reviewers for their useful comments and suggestions.

References Addai, I. (1999). Does religion matter in contraceptive use among Ghanaian women? Review of Religious Research, 40, 259–277. American Medical Association. (2002). H-20.930 counselling and testing of pregnant women for HIV. Website: http://

ARTICLE IN PRESS I.N. Luginaah et al. / Social Science & Medicine 61 (2005) 1689–1700 www.ama-assn.org/apps/pf_online/pf_online?f_n=browse ypolicyles/HOD/H-20.930.HTM (date accessed: 22 July 2003). Appadurai, A. (1996). Modernity at large: Cultural dimensions of globalization. Minneapolis: University of Minnesota Press. Asiimwe-Okiror, G., Opio, A. A., Musinguzi, J., Madraa, E., Tembo, G., & Carae¨l, M. (1997). Change in sexual behaviour and decline in HIV infection among young pregnant women in urban Uganda. AIDS, 11, 1757–1763. Assimeng, M. (1989). Religion and social change in West Africa. Accra: Ghana Universities Press. Christian Century. (2000). AIDS and the church in Africa. No. 22, August 2–9. Coyne-Beasley, T., & Schoenbach, V. J. (2000). The African–American church: A potential forum for adolescent comprehensive sexuality education. Journal of Adolescent Health, 26, 289–294. Danziger, R. (1996). Compulsory testing for HIV in Hungary. Social Science & Medicine, 43(8), 1199–1204. Eden, D. L. (2001). Is it constitutional and will it be effective? An analysis of mandatory HIV testing of pregnant women. Health Matrix, 11(2), 659–686. Elifson, K. W., Klein, H., & Sterk, C. E. (2003). Religiosity and HIV risk behaviour involvement among ‘‘at risk’’ women. Journal of Religion and Health, 42(1), 47–66. Endstad, R. (1989). AIDS test has 40,000 fleeing state to wed. Chicago Tribune, California, 4 January 1989. Flanagan, W. F. (2001). HIV/AIDS and human rights in Russia: Compliance and the rule of law. Osgoode Hall Law Journal, 39(1), 39–76. Fombad, C. D. (2001). The crisis of confidentiality in the control of HIV/AIDS pandemic in Botswana. International Social Science Journal, 53(170), 643–656. Freeman, M. (1998). Human rights and real cultures: Towards a dialogue on ‘‘Asian Values’’. Netherlands Quarterly of Human Rights, 16(1), 25–39. Gallup International. (2000). Religion in the world at the end of the millennium. Gallup International. Website: http:// www.gallup-international.com (date accessed: 16 October, 2003). Garner, R. C. (2000). Safe sects? Dynamic religion and AIDS in South Africa. The Journal of Modern African Studies, 38(1), 41–69. Georgia Division of Public Health. (2003). Premarital testing in Georgia. http://www.ph.dhr.state.ga.us/programs/vitalrecords/premaritalbloodtest.shtml (date accessed: November 28, 2003). Ghana National Anti-AIDS Commission (GNACC). (2002). Anti-AIDS commission against mandatory testing. Ghana News Agency, June 27. http://www.ghanaweb.com/Ghana HomePage/NewsArchive/artikel.php?ID=25167 (date accessed: 29 June, 2003). Ghana News Agency. (2003). AIDS awareness campaign goes to Nkawkaw. http://www.ghanaweb.com/GhanaHomePage/ NewsArchive/artikel.php?ID=33842 (date accessed: 7 July 2003). Ghanaian Times. (2002). Minister advises isolation and protection of virgins. http://www.ghanaweb.com/GhanaHome Page/NewsArchive/artikel.php?ID=25601 (date accessed: 20 July, 2003).

1699

Ghanaweb. (2002). Miss virgins HIV/AIDS: Pageant to extol virtues of virginity. http://www.ghanaweb.com/ GhanaHomePage/NewsArchive/artikel.php?ID=29811 (date accessed: 20 July 2003). Gomoa District Assembly. (2002). Assembly to honour proven virgins. Ghana News Agency, December 16. http://www. ghanaweb.com/GhanaHomePage/NewsArchive/artikel.php ?ID=30606 (date accessed: 15 July 2003). Ilcan, S. (2002). Longing in belonging: The cultural politics of settlement. London: Praeger. International Covenant on Civil and Political Rights. (1976). General Assembly resolution 2200A (XXI). United Nations High Commissioner for Human Rights. Website: http:// www.unhchr.ch/html/menu3/b/a_ccpr.htm (date accessed: 30 June 2003). International Covenant on Economic, Social and Cultural Rights. (1976). General Assembly resolution 2200A (XXI). United Nations High Commissioner for Human Rights. Website: http://www.unhchr.ch/html/menu3/b/a_cescr.htm (date accessed: 30 June 2003). Jemmott, L. S., Catan, V., Nyamathi, A., & Anastasia, J. (1995). African American women and HIV-risk-reduction issues. In A. O’Leary, & L. S. Jemmott (Eds.), Women at risk: Issues in primary prevention of AIDS (pp. 131–157). New York: Plenum. Kidd, S. P., & Parshall, B. M. (2000). Getting the focus and the group: Enhancing analytical rigor in focus group research. Qualitative Health Research, 10(3), 293–308. Kilian, A. H. D., Gregson, S., Ndyanabangi, B., Walusaga, K., Kipp, W., Sahlmu¨ller, G., Garnett, G. P., Asiimwe-Okiror, G., Kabagambe, G., Weis, P., & von Sonnenburg, F. (1999). Reductions in risk behaviour provide the most consistent explanation for declining HIV-1 prevalence in Uganda. AIDS, 13(5), 391–398. Kitzinger, J. (1995). Qualitative research: introducing focus groups. British Medical Journal, 311, 299–302. Krefting, L. (1991). Rigor in qualitative research: The assessment of trustworthiness. American Journal of Occupational Therapy, 45(3), 214–222. Lagarde, E., Enel, C., Seck, K., Gueye-Ndiaye, A. L., Piau, J. P., Pison, G., Delaunay, V., Ndoye, I., & M’Boup, S. (2000). Religion and protective behaviours towards AIDS in rural Senegal. AIDS, 14, 2027–2033. Leclerc-Madlala, S. (2001). Virginity testing: managing sexuality in the maturing HIV/AIDS epidemic. Medical Anthropology Quarterly, 15(4), 533–552. Meda, N., Ndoye, I., M’Boup, S., Wade, A., Ndiaye, S., Niang, C., Sarr, F., Diop, I., & Carae¨l, M. (1999). Low and stable HIV infection rates in Senegal: Natural course of the epidemic or evidence for success of prevention? AIDS, 13, 1397–1405. Mekonnen, Y., Sanders, E., Aklilu, M., Tsegaye, A., Rinke deWit, T. F., Schaapa, A., Wolday, D., Geskus, R., Coutinho, R. A., & Fontanet, A. L. (2003). Evidence of changes in sexual behaviours among male factory workers in Ethiopia. AIDS, 17, 223–231. Nukunya, G. (1992). Tradition and change in Ghana: An introduction to sociology. Accra, Ghana: Ghana Universities Press. Parker, R. (2001). Sexuality, culture and power in HIV/AIDS research. Annual Review of Anthropology, 30, 163–179.

ARTICLE IN PRESS 1700

I.N. Luginaah et al. / Social Science & Medicine 61 (2005) 1689–1700

Patton, M. (1987). How to use qualitative methods in evaluation. Thousand Oaks, CA: Sage Publications. Robinson-Jacobs, K. (1998). Black churches urged to do more in fight against AIDS. New York Times, February 21 (pp. B4–B5). Sohail, A. (2002). Declines in casual sex in Lusaka, Zambia: 1996–1999. AIDS, 16(2), 291–293. Stolberg, S. (1998). Eyes shut, Black American is being ravaged by AIDS. New York Times, July 29 (pp. A1–A12). Stone, T.H. (1998). Mandatory testing of prisoners. http:// www.law.uh.edu/healthlawperspectives/Correctional/980916 Mandatory.html (date accessed: November 28, 2003). Stoneburner, R. L., & Low-Beer, D. (2004). Population-level HIV declines and behavioral risk avoidance in Uganda. Science, 304, 714–718. Strauss, A., & Cobin, J. (1990). Basics of qualitative research. Grounded theory procedures and techniques. Thousand Oaks, CA: Sage Publications. Takyi, B. K. (2003). Religion and women’s health in Ghana: Insights into HIV/AIDs preventive and protective behavior. Social Science & Medicine, 56, 1221–1234. Takyi, B., & Addai, I. (2002). Religious affiliation, marital processes and women ‘s educational attainment in a developing society. Sociology of Religion, 63, 177–193. Tobias, B. Q. (2001). A descriptive study of the cultural mores and beliefs toward HIV/AIDS in Swaziland, Southern Africa. International Journal for the Advancement of Counselling, 23, 99–113. UNAIDS. (1998a). A measure of success in Uganda: The value of monitoring both HIV prevalence and sexual behavior. UNAIDS case study. UNAIDS Best Practices Collection 98.8, Geneva.

UNAIDS. (1998b). HIV/AIDS and human rights: International guidelines. Office of the United Nations High Commissioner for Human Rights and the Joint United Nations Programme on HIV/AIDS, Supp. No. 40, UN Doc. HR/PUB/ 98/1, online: UNCHR Homepage http://www.unaids. org/publications/documents/human/index.html#ethics (date accessed: 17 July 2003). UNAIDS (2000). Report on the global HIV/AIDS epidemic. Joint United Nations Programme on HIV/AIDS, Geneva. Website: http://www.unaids.org/epidemic_update/report/ Epi_report.pdf (date accessed: 20 July 2003). United Nations. (1998). Levels and trends of contraceptive use as assessed in 1998. New York: Department of Economic and Social Affairs, Population Division, United Nations. Universal Declaration of Human Rights, General Assembly resolution 217 A (III). (1948). United Nations. Website: http://www.un.org/Overview/rights.html (date accessed: 26 June 2003). USAID. (2000). Voluntary HIV/AIDS counseling and testing: Many Africans do want to know. Washington, DC 20523. Press Office. Website: http://www.usaid.gov/press/releases/ 2000/fs000712_2.html (date accessed: 12 October 2003). Van Ness, P. H. (1999). Religion and public health. Journal of Religion and Health, 38(1), 15–26. Varga, C. A. (1997). Sexual decision-making and negotiation in the midst of AIDS: Youth in Kwazulu Natal, South Africa. Health Transition Review, 7(Suppl. 2), 13–40. Woodward, K. (2001). The changing face of the Church. Newsweek, April 16 (pp. 46–52). Worthington, H. (1997). Where voluntary testing has produced results. AIDS Analysis Africa, 7(6), 3.