Elsevier

Social Science & Medicine

Volume 61, Issue 8, October 2005, Pages 1689-1700
Social Science & Medicine

From mandatory to voluntary testing: Balancing human rights, religious and cultural values, and HIV/AIDS prevention in Ghana

https://doi.org/10.1016/j.socscimed.2005.03.034Get rights and content

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.

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 reduction in number of sex partners and casual sex, abstinence among unmarried youth (Stoneburner & Low-Beer, 2004), and increased condom use (Asiimwe-Okiror 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., 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 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 programmes at the local level and improving health policy and health services delivery.

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 HIV-related 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).

The various dimensions of culture distinguish one group of people from another (Ilcan, 2002; Appadurai, 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 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 socio-economic 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.

Section snippets

Methods

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 unknown themes to emerge, and allow for interviewer responsiveness. The

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.

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

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 (56)

  • K.W. Elifson et al.

    Religiosity and HIV risk behaviour involvement among “at risk” women

    Journal of Religion and Health

    (2003)
  • Endstad, R. (1989). AIDS test has 40,000 fleeing state to wed. Chicago Tribune, California, 4 January...
  • W.F. Flanagan

    HIV/AIDS and human rights in Russia: Compliance and the rule of law

    Osgoode Hall Law Journal

    (2001)
  • C.D. Fombad

    The crisis of confidentiality in the control of HIV/AIDS pandemic in Botswana

    International Social Science Journal

    (2001)
  • M. Freeman

    Human rights and real cultures: Towards a dialogue on “Asian Values”

    Netherlands Quarterly of Human Rights

    (1998)
  • Gallup International. (2000). Religion in the world at the end of the millennium. Gallup International. Website:...
  • R.C. Garner

    Safe sects? Dynamic religion and AIDS in South Africa

    The Journal of Modern African Studies

    (2000)
  • Georgia Division of Public Health. (2003). Premarital testing in Georgia....
  • Ghana National Anti-AIDS Commission (GNACC). (2002). Anti-AIDS commission against mandatory testing. Ghana News Agency,...
  • Ghana News Agency. (2003). AIDS awareness campaign goes to Nkawkaw....
  • Ghanaian Times. (2002). Minister advises isolation and protection of virgins....
  • Ghanaweb. (2002). Miss virgins HIV/AIDS: Pageant to extol virtues of virginity....
  • Gomoa District Assembly. (2002). Assembly to honour proven virgins. Ghana News Agency, December 16....
  • S. Ilcan

    Longing in belonging: The cultural politics of settlement

    (2002)
  • International Covenant on Civil and Political Rights. (1976). General Assembly resolution 2200A (XXI). United Nations...
  • International Covenant on Economic, Social and Cultural Rights. (1976). General Assembly resolution 2200A (XXI). United...
  • L.S. Jemmott et al.

    African American women and HIV-risk-reduction issues

  • S.P. Kidd et al.

    Getting the focus and the group: Enhancing analytical rigor in focus group research

    Qualitative Health Research

    (2000)
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