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By
Ahmed R. A. Ragab, Mervat Mahmoud and G.I. Serour
Background
The adult prevalence rate for HIV in the Middle
East and North Africa reached 0.3% in 2003, equal
to that of Western Europe. However, while 35,000
new cases occurred in Western Europe in 2003, 55,000
new cases were estimated to have occurred in the
Middle East and North Africa region during the same
period. The estimated cases in 2004 came to 92,000.
Similarly, the estimated number of deaths resulting
from AIDS in 2003 was 45,000 in the region compared
to only 3000 in Western Europe. These figures show
the relative containment of the epidemic in Western
Europe, while the same epidemic is rapidly expanding
in the Middle East and North Africa region [1]
Strong taboos attached to HIV/AIDS in the Middle
East and North Africa make it harder to measure
the scope of the problem and to plan accordingly.
Extreme stigma not only marginalizes those who are
HIV-positive but also inhibits people from going
for tests in the first place [2,3].
It is commonly believed that the region’s
conservative socio-cultural norms and the relatively
good health expenditures in some countries have
helped to limit HIV spread.
Rationale
The difficulty in establishing effective HIV/AIDS
programmes comes from a lack of openness to sexuality
issues in many of the Muslim countries. There is
also the added factor of the attitude to illness
and death. As a result of deep-rooted cultural constructs,
these are considered taboo subject areas.
We also find that religion is a very important
factor in Egyptian history, in shaping the attitudes
and the behaviours of large sections of the population.
Religious leaders are the gate keepers for many
social and cultural issues. The role of religious
leaders is not restricted only to the call for prayer,
fasting, almsgiving, pilgrimage and other religious
commandments and juristic regulations; but this
role extends to include other social obligations
such as mobilising people for various medical, social,
cultural and religious activities.
Recognising the roles that religious leaders play;
and involving them in HIV and AIDS programmes will
lead to greater success.
Most of the programmes that involve religious leaders
operate on the premise that religious leaders only
need information to become effective partners in
the fight against AIDS. There has been little attempt
to understand what they can contribute and what
their specific needs are. This study examined what
the religious leaders can contribute to the success
of HIV/AIDS programmes including the provision of
care for PLWHA. The research also sought to establish
what religious leaders need in order to fulfil these
tasks.
Research Objectives
The research aimed to: (1) Find out what religious
leaders know about HIV/AIDS (2) Examine the attitude
of religious leaders to PLWHA (3) Find out what
religious leaders can contribute to HIV/AIDS programmes;
including care and support for PLWHA (4) ascertain
the needs of the religious leaders in order to engage
them in the fight against HIV/AIDS.
Methodology:
The research was conducted in one of the Upper Egypt
Governorates (Beni-Suif) and in one Governorate
in Lower Egypt (El-Sharkia). This was a cross-sectional
analytical study, utilising two types of qualitative
research - focus group discussions (FGDs) for different
target groups and in-depth interviews with 12 religious
Leaders.
Group Selection
Based on the objectives of the study, the groups
were selected in collaboration with the local authorities
and with existing non-governmental organisations
(NGOs).
Focus Group Guide:
The questions were arranged in a natural, logical
sequence and were memorized by the moderator. Although
the first part of the focus group guide was fixed
for all groups, the second part was flexible so
that it could be adapted to suit the different groups.
In-Depth Interviews were conducted using a carefully
designed questionnaire. This added more depth to
the study findings.
Quality Control
The measures that were taken to improve the reliability
of the research findings included the following:
The use of combined focus groups and in-depth interview
techniques; Repeat questions were incorporated in
both the focus groups and in-depth interviews and
were used to check the consistency of response.
Human factors like fatigue, mental capacity, and
limited hours, were adequately considered.
Research Findings
The findings of both focus group discussion and
the in-depth interviews were analysed as follows:
Knowledge about HIV/AIDS:
the religious leaders displayed varying knowledge
levels regarding preventive measures and the modes
of transmission of HIV and AIDS. Apparently, many
were influenced by HIV and AIDS programmes that
they had attended in the past. While those who attended
a previous programme (seminar or workshop) had good
knowledge, the others had many misconceptions and
wrong ideas.
"HIV/AIDS is transmitted in situations
of adultery and among homosexuals or lesbians; or
when one has sex with a menstruating woman or with
an animal" (A religious leader who never
attended a sensitisation programme, Upper Egypt).
"HIV/AIDS is transmitted through an infected
mother to child. It could also be transmitted while
having sex with an infected person who is normal
[meaning heterosexual], HIV can be transmitted if
one is injecting drugs and sharing needles in a
group where one of the members is infected. It can
also be transmitted through a blood transfusion
if the blood was taken from an infected person"
(A religious leader who had a attended a previous
sensitization programme).
Very few of the respondents showed a severe lack
of information:
"HIV/AIDS can be transmitted through sneezing,
shaking hands with an infected person, insects bites,
having anal sex, sex with animals and sex with menstruating
women" (A religious leader from Upper
Egypt).
The common believe that it is a disease without
treatment was obvious. The group affirmed that infected
people are dead people. "it is the most
dangerous disease in this current age; people who
are infected are going to die in a short period"
One religious leader from Lower Egypt suggested
that "This disease is Allah’s punishment
for those adulterers, sinners and homosexuals".
Prevention of HIV: In
spite of the different modes of transmission that
was mentioned, when the groups members were asked
about prevention issues, the following were some
of the repeated answers: "Avoiding adultery
is the way", "adhering to Allah's teaching",
"avoiding homosexuality", "avoiding
sexual intercourse through any route other than
vaginal intercourse”, "Avoiding sex with
menstruating women".
A religious leader from Upper Egypt explained further:
"It is not only avoiding these behaviours
that is important; but also avoiding what may lead
or expose one to these behaviours such as mixing
between boys and girls, a meeting in private between
a man and a strange woman [who is not his wife or
sister], and other things that lead to adultery"
Very few suggested using sterilized dental instruments
and only one person suggested the use of disposable
injection needles. However, there was a consensus
on the need for a special form of sexuality education
that is based on religious teachings. They also
stressed the need to avoid sex outside marriage.
This education, as the groups observed, should be
delivered in a sensitive and courteous way. One
religious leader gave the following example.
"At the time of the Prophet (PBUH), a
young man came to him to ask for permission to commit
adultery! The prophet’s companions were surprised
and wanted to beat the young man up but the Prophet
(PBUH) stopped them. He asked the young man: ‘Would
you accept this [committing adultery] for your mother?
The young man said ‘No’. Then the Prophet
(PBUH) asked him: Do you accept this for your sister?
The man said ‘No’. The Prophet continued
asking him about all his close relatives and the
answer was a constant ‘no’. Then, the
Prophet told him ‘and also other Muslims do
not accept it for their wives’. The young
man went very convinced, and as we notice the Prophet
(PBUH) did not punish the young man”.
Condom Rejected: Probing
technique was utilised on the issue of condom use.
There was a general rejection of the condom. The
religious leaders affirmed that this method could
open the way to adultery and this is unacceptable
by Islam. The only acceptable way condom can be
used, as they affirmed, is between a husband and
wife; and this is also on the condition that there
is a mutual agreement between the husband and wife.
Other prevention strategies cited included: mass
screening of all travellers to Egypt (including
the nationals); screening of those who are entering
the labour force (with special emphasis on those
who are going to work close to food products and
those who are barbers and dentists). Screening of
all those who are admitted to the universities,
and making the HIV test a compulsory test before
marriage were also suggested
Attitude Towards People Living with
HIV/AIDS: The religious leaders affirmed
that human life is highly valued in Islam; it is
considered a gift from Allah and it was also pointed
out that Holy Prophet Mohammed, (PBUH), stressed
the importance of health at many times.
One religious leader from Upper Egypt affirmed
that "Our bodies are on trust from Allah
and must be returned one day. We will be asked,
among other things, how we looked after it".
Therefore, he continued "we should avoid
any act which will harm our health". He
further suggested, “we should segregate/isolate
those people [PLWHA], so we can avoid the infections".
However the majority rejected the idea of isolation
because: "Islam is a religion that is full
of compassion, love and mercy. The Prophet Muhammad
(PBUH) stated that: “You will not enter into
paradise until you believe, and you will not believe
until you love one another”, a religious leader
from Upper Egypt affirmed and suggested instead
that "We should treat those people with mercy”.
However, he continued, “we should be careful,
as the prophet (PBUH) acknowledged the need to avoid
infection".
A religious leader from Lower Egypt quoted this
Hadith "The Prophet (PBUH) asked us to “escape
from Plague as though you are escaping from a Lion."
Another religious leader from Lower Egypt indicated
"in Islam, if you are in an area where there
is an outbreak of the Plague, you should not leave
it for fear of infection.”
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Table
1. How To Prevent Mother To Child Transmission |
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P1: Transmission
to the children should be prevented; doctors
should tell us how we can ensure that
P2:
PLWHA should not marry and those who are married
should avoid pregnancy
P3:
In this case, condoms can be used
P4:
What about women who are pregnant already?
P5: In this case abortion could
be an option
P6: abortion
cannot be allowed after 120 days
P7:
no, abortion is allowed only before 40 days
P8: can we know for sure
that the coming child will be infected?
P9: we need full medical information
on this and other issues in order to make our
Fatwa (rule). |
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A religious leader from Upper Egypt suggested that
there was a strong feeling among the religious leaders
that PLWHA should be treated with mercy. "It
is enough the suffering that they have. The Prophet
said: “Allah shows compassion only to those
of his servants who are compassionate.”
Some of the religious leaders expressed the fear
that the stigma surrounding PLWHA could force them
to seek revenge on society by spreading the virus.
Prevention of Mother to Child Transmission:
One major concern which was expressed
by many of the participants was how to prevent mother
to child transmission of the virus. See Table 1
for excerpts from a FGD held in Upper Egypt
What Can Religious Laders Do and What
Do Religious Leaders Need in Order to be involved?
There was a consensus that religious leaders can
contribute much to the efforts to tackle the problem
of HIV/AIDS. Table 2 has excerpts from one of the
focus group discussions in Upper Egypt.
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Table
2 |
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| What
Religious Leaders Can Do |
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What
They Need |
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P1:
We can motivate youth to be adherent to tehe
teachings of Islam and avoid adultery
P2: We can advice the community
to treat PLWHA kindly, to help them and to treat
them as people who are sick and not criminals
P3: We can ban drugs and narcotics"
P4: We can promote chastity
among the whole community
However, there was a concern about how to
address the subject as follows:
P5: We need to address this
issue in seminars in youth clubs or the afternoon
lessons; not in the Friday prayer
P6: In this case we need
to collaborate with medical doctors; the medical
doctors will counsel from a medical point
of view and we will counsel from the religious
point of view
P2: We can also participate
in the hotline, services. So, a medical doctor
and a religious leader can answer the questions
and concerns of the people;
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P1:
"We need information on ways to stop transmission
of the virus. Is there a vaccine that can be
taken? How I can know that the person that I
am talking to is HIV positive?"
P1: people look at us as though
we are angels, flour is not sold with the words
'well done', and we are human beings.
P3: the government should recognize
that we are a special group of the society and
we need to be satisfied financially in order
to carry on our job probably.
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Conclusion
Islam has always encouraged discussions of matters
which will help protect health and life. Muslim
men and women never felt shy to ask the Prophet
(PBUH) about intimate sexual matters. The Holy Qur’an
discusses reproduction and sexual health.
Love and compassion are the qualities of a good
Muslim. People living with HIV/AIDS cannot be denied
compassion. People PLWHA need compassion, love,
and affection, in addition to social and material
support. There are many sayings from the Prophet
about showing love, compassion and support to people
in ill health.
Thus, religious leaders can contribute to the efforts
aimed at prevention of HIV/AIDS and caring for PLWHA.
Religious leaders can contribute to advocacy programmes
in their mosques, and through seminars and written
articles. They can also be involved in the running
of AIDS hotlines.
However, in order for them to play these roles,
the religious leaders require the following:
• Financial empowerment
• Strategic raining programmes
• Access to information, (through seminars,
information materials and audio visual aids (like
posters, flyers, audio tapes, video tapes and CDs).
Acknowledgments
The authors would like to acknowledge the Africa
Faith Based Forum for supporting this research.
In addition, special thanks go to our partners in
Egypt - Coptic Evangelical Organisation for Social
Service (CEOSS) and Caritas for their moral and
technical support. Furthermore, we acknowledge the
contributions of our key informants, the religious
leaders in Upper and Lower Egypt, who gave us the
courage and wisdom to conclude this research.
References
1. UNAIDS Fact Sheet (2004); UNAIDS and WHO 2003.
UNAIDS fact sheet on the AIDS epidemic in the Middle
East and North Africa, accessible online at http://www.unaids.org/Unaids/EN/Geographical+area/By+Region/North_Africa_Middle_East.asp
2. Carol Jenkins (2004) “Vulnerability to
HIV/AIDS in the Middle East and North Africa: A
Socio-Epidemiology Overview,” Paper given
at Twenty-Fifth International AIDS Conference, Satellite
Meeting of Global Researchers of HIV/AIDS in the
Middle East and North Africa Region, Bangkok, Thailand,
July 13.
3. Carol Jenkins and David Robalino (2003), HIV/AIDS
in the Middle East and North Africa: The Costs of
Inaction. Washington, DC: World Bank.World
Bank, AIDS Regional Update: Middle East and North
Africa, “An Opportunity for Prevention: HIV/AIDS
Situation in the Middle East and North Africa Region.”
* Ahmed R. A. Ragab, MD Ph.D; Mervat Mahmoud,
Ph.D; and Prof. Dr. G.I. Serour, FRCOG, FRCS are
at The International Islamic Centre for Population
Studies and Research, Al-Azhar University; a Faith-Based
Forum Partner in Egypt.
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