Religion and HIV diagnosis among Africans living in London

Authors


Correspondence: Ms Ibidun Fakoya, Centre for Sexual Health & HIV Research, Mortimer Market Centre, Off Capper Street, London WC1E 6JB, UK. Tel: +44 [0] 20 3108 2066; fax: +44 [0] 20 3108 2058; e-mail: ibidun.fakoya@ucl.ac.uk

Abstract

Objectives

The aim of the paper was to describe the association of religion with HIV outcomes in newly diagnosed Africans living in London.

Methods

A survey of newly diagnosed HIV-positive Africans attending 15 HIV treatment centres across London was carried out between April 2004 and February 2006. Confidential self-completed questionnaires were used, linked to clinical records. Bivariate analyses were conducted to ascertain whether religious beliefs were associated with late diagnosis, antiretroviral therapy, and immunological and virological outcome 6 months post diagnosis.

Results

A total of 246 Black Africans were eligible and included in the analysis: 62.6% were women, and the median age was 34 years. The median CD4 count at diagnosis was 194 cells/μL (range 0–1334 cells/μL) and 75.6% presented late, as defined as a CD4 count < 350 cells/μL. Most participants were religious: non-Roman Catholic Christians (55.7%), Roman Catholics (35.2%) and Muslims (6.1%). Only 1.2% stated that they did not have a religion. Participants who attended religious services at least monthly were more likely to believe that ‘faith alone can cure HIV‘ than those who attended less frequently (37.7% vs. 15.0%; P = 0.002). A small proportion (5.2%) believed that taking antiretroviral therapy implied a lack of faith in God. Bivariate analysis found no relationship between religiousness (as measured using frequency of attendance at religious services and religious attitudes or beliefs) and late diagnosis, changes in CD4 count/viral load 6 months post diagnosis, or initiation of antiretroviral therapy.

Conclusions

Strong religious beliefs about faith and healing are unlikely to act as a barrier to accessing HIV testing or antiretroviral treatment for Black Africans living in London.

Introduction

Although men who have sex with men remain the largest group affected by HIV in the UK, heterosexual Black Africans bear a disproportionate burden of the HIV epidemic in the UK [1]. In 2009, Black Africans accounted for just over a third (33.8%) of all new HIV diagnoses and 63% of heterosexuals diagnosed with HIV infection in the UK [1]. Approximately one third (32.2%) of HIV-positive Black Africans are living with undiagnosed HIV infection. In 2009, 59% of heterosexual women and 66% of heterosexual men were diagnosed late (that is, with a CD4 count < 350 cells/μL); nearly double the proportion of late diagnoses among White men who have sex with men (39%) [1].

There is very little UK-based research exploring the impact that faith communities and belief in God have on HIV-related health-seeking behaviours [2]. Faith and traditional sacred beliefs are often important to people from African communities in the UK and they are more likely than other ethnicities to identify as belonging to a religion [3]. In the 2001 UK census, 68.8% of Black Africans identified as Christian and 20% as Muslim [4].

This paper examines the role of religion in the lives of newly diagnosed Africans living in London. Using the findings of a survey, it describes the importance of religion to study participants, examining their attitudes towards and beliefs regarding prayer and healing and whether this was associated with HIV-related health-seeking behaviours and outcomes.

Methods

The Study of Newly Diagnosed HIV Infection among Africans in London (SONHIA) is a survey of newly diagnosed HIV-positive Africans attending 15 HIV treatment centres across London conducted between April 2004 and February 2006. Eligible participants were clinic attendees aged 18 years and over, born or raised in Africa (regardless of racial or ethnic group), and diagnosed with HIV infection in the preceding year. A detailed description of the design and recruitment process has previously been published [5]. Only participants who identified as Black African were included in this analysis.

Recruited participants undertook a self-completion pen and paper questionnaire, available in English or French, which was linked to clinician-completed clinical records. The questionnaire collected quantitative data on sociodemographic characteristics, and behavioural and social factors, including religious observance, the importance of religion and attitudes and beliefs about healing and medication.

Analysis

Data were entered into a secure database and systematically checked for errors prior to statistical analysis. The main outcomes were belief in the ability of HIV infection to be healed through prayer, and late presentation, defined as a CD4 count below 350 cells/μL at the time of HIV diagnosis. Standard bivariate statistical tests, for example the χ2 test or Fisher's exact test, were used to describe associations between outcomes. Logistic regression modelling was used to obtain odds ratios. Statistical significance was defined at 0.05.

A description of the sample and summary statistics performed using spss 14.0 (SPSS Inc., Chicago, IL) are presented here.

Ethics

The study was granted approval by the London Multicentre Research Ethics Committee (MREC/03/2/105).

Results

Across the 15 recruitment centres, 710 patients were identified as eligible for the larger SONHIA study; 109 (15.4%) were lost to follow-up and 17 died before they could be approached to participate; 60% of the remaining patients (352 of 584) were approached, of whom 79.5% (280 of 352) agreed to participate in the study. In total, 263 questionnaires were completed, of which 93.5% (246) were completed by Black Africans and therefore included in this analysis. Patients not approached did not differ significantly from those participating in terms of gender or age, but were less likely to come from southern and eastern Africa (57.9 vs. 73.0%; p < 0.001). The median CD4 count of those participating was 200 cells/μL, while for those not approached it was 260 cells/μL. The median time between HIV diagnosis and questionnaire completion was 3.5 months.

Characteristics of respondents

The median age of respondents was 34 years (range 18–62 years). Men were slightly older than women (median age 37 vs. 34 years, respectively; P = 0.002) and were significantly more likely to be in full-time employment (44.6 vs. 28.0%, respectively; P = 0.042) (Table 1). The median CD4 count at diagnosis was 194 cells/μL (range 0–1334 cells/μL) and 75.6% had a CD4 count < 350 cells/μL (50.6% < 200 cells/μL) at diagnosis. The majority of respondents were heterosexual (91.5%), although 7.6% of men identified as homosexual or bisexual.

Table 1. Characteristics of male and female participants
Characteristicsa Gender  
Male (n = 92)Female (n = 154)Total (n = 246) P-valueb
  1. aBase varies because of missing data.
  2. bχ2 test for association or Fisher's exact test.
Sociodemographic    
Age (years) [median (range)]37 (22–57)33 (18–62)34 (18–62)0.002
Employment [n (%)]   0.042
Full-time education12 (13.0)35 (23.3)47 (19.4) 
Employed full-time41 (44.6)42 (28.0)83 (34.3) 
Employed part-time13 (14.1)23 (15.3)36 (14.9) 
Unemployed26 (28.3)50 (33.3)76 (31.4) 
Sexuality [n (%)]   0.007
Heterosexual80 (87.0)145 (94.2)225 (91.5) 
Homosexual or bisexual7 (7.6)4 (2.5)8 (3.3) 
Education [n (%)]   0.237
O-level equivalent21 (23.1)39 (25.7)60 (24.7) 
A-level equivalent20 (22.0)31 (20.4)51 (21.0) 
Diploma/NVQ/RN11 (12.1)29 (19.1)40 (16.5) 
Degree31 (34.1)34 (22.4)65 (26.7) 
Other/none8 (8.8)19 (12.5)27 (11.1) 
CD4 count at diagnosis (cells/μL) [median (range)]152 (0–700)204 (1–1333)194 (0–1333)0.073
Religious    
Religion (n = 244) [n (%)]   0.861
Roman Catholic32 (34.8)54 (35.5)86 (35.2) 
Non-Roman Catholic Christian50 (54.3)86 (56.6)136 (55.7) 
Muslim7 (7.6)8 (5.3)15 (6.1) 
Other1 (1.1)3 (1.9)4 (1.6) 
None2 (2.2)1 (0.6)3 (1.2) 
Religious attendance (n = 240) [n (%)]   0.003
Weekly or more34 (37.4)92 (61.7)126 (52.5) 
Monthly or more28 (30.8)25 (16.8)53 (22.1) 
Once or twice a year20 (22.0)23 (15.4)43 (17.9) 
Practically never9 (9.9)9 (6.0)18 (7.5) 
Importance of religion (n = 243) [n (%)]   0.039
Very important56 (61.5)118 (77.6)174 (71.6) 
Important25 (27.5)26 (17.1)51 (21.0) 
Neither important nor unimportant9 (9.9)8 (5.3)17 (7.0) 
Not important at all1 (0.4)-1 (0.4) 
Received HIV information from clergy/ faith-based organization prior to HIV test [n (%)]6 (2.4)13 (5.3)19 (7.7)0.772
Faith alone can cure HIV [n (%)]   0.009
No54 (60.0)67 (44.4)121 (50.2) 
Yes18 (20.0)59 (39.1)77 (30.6) 
Don't know18 (20.0)26 (16.6)47 (17.8) 
Medicines imply lack of faith [n (%)]   0.317
No78 (87.6)127 (84.7)205 (85.8) 
Yes2 (2.2)10 (6.7)12 (5.0) 
Don't know9 (12.9)13 (8.7)22 (9.2) 

Nearly all respondents were part of a religious group – only three study participants (1.2%) stated that they did not have a religion. Most participants were non-Roman Catholic Christians (55.7%) or Roman Catholics (35.2%), with 6.1% identifying as Muslims. Women were more likely to attend religious services on a regular basis, with 61.7% attending at least once a week compared with 37.4% of men. Religion was seen as important or very important to nearly all respondents, regardless of gender, and only one respondent said that religion was not important at all. A small proportion (7.7%) of participants had received HIV information from clergy/faith-based organizations prior to the HIV test.

Role of religion

Participants were asked questions about their attitudes and beliefs about religion. Table 2 compares those who attend religious services once a month or more with those who attend twice a year or less. Participants who attended religious services at least monthly were more likely to believe that ‘faith alone can cure HIV’ than those who attended twice a year or less (37.7 vs. 15.0%, respectively; P = 0.001). Although women were more likely to hold this belief (39.1 vs. 20.0%, respectively; P = 0.008), they also attended religious services with greater frequency than men and viewed religion with greater importance. Overall, the proportion of participants who believed that taking antiretroviral therapy implied a lack of faith in God was 5.2%; these respondents were more likely to be Christians (91.7 vs. 8.3%, respectively; P = 0.036; data not shown). There was no significant difference in the percentage holding this belief according to frequency of church/mosque attendance, age or gender. Some participants (6.6%) reported that they had been deterred from testing for HIV because they believed that ‘God could protect them’ from the virus. On the whole, compared with non-Muslims, fewer Muslim respondents reported that they attended religious services on an at least monthly basis, Muslims were less likely to believe in the power of faith to cure HIV infection (7.1 vs. 33.0%, respectively; P = 0.016) and no Muslims believed that the use of medicines implied lack of faith (0.0 vs. 5.4%, respectively; P = 0.012).

Table 2. Comparison of attitudes or beliefs about faith and healing and clinical characteristics of subjects according to attendance at religious services
 Attendance at religious services 
 Monthly or more (n = 179)Twice a year or less (n = 61)Total (n = 240) P-valueb
  1. ART, antiretroviral therapy.
  2. aBase varies because of missing data.
  3. bχ2 test for association or Fisher's exact test.
Faith alone can cure HIVa [n (%)]   0.002
No84 (48.0)34 (56.7)118 (50.2) 
Yes66 (37.7)9 (15.0)75 (31.9) 
Don't know25 (14.3)17 (28.3)42 (17.9) 
Medicines imply lack of faitha [n (%)]   0.110
No154 (88.5)46 (78.0)200 (85.8) 
Yes8 (4.6)4 (6.8)12 (5.2) 
Don't know12 (6.9)9 (15.3)21 (9.0) 
People who are HIV-positive are at risk of isolation if their church/mosque finds out about their diagnosisa [n (%)]   0.337
Agree69 (40.8)21 (37.5)90 (40.0) 
Neither agree nor disagree38 (22.5)18 (32.1)56 (24.9) 
Disagree62 (36.7)17 (30.4)79 (35.1) 
No point [in having HIV test] as God will protect mea [n (%)]11 (6.5)4 (6.8)15 (6.6)0.938
CD4 count at diagnosisa (cells/μL) [median (range)]190 (0–1333)200 (0–855)194 (0–1333)0.460
Late presentationa (CD4 < 350 cells/μL) [n (%)]139 (77.7)44 (72.1)183 (76.6)0.388
Advanced disease at presentationa (CD4 < 200 cells/μL) [n (%)]97 (54.2)31 (50.8)128 (53.3)0.649
ART since diagnosisa [n (%)]50 (28.9)22 (37.9)72 (31.2)0.199
Undetectable viral load (< 50 copies/ml) 6 months post diagnosisa [n (%)]76 (62.3)28 (77.8)105 (65.8)0.085
Change in CD4 count at 6 monthsa (cells/μL) [median (range)]63 (−592 −949)41 (−121 −780)60 (−592 −949)0.294

Fewer than one in ten participants had received HIV/AIDS information from faith leaders or faith-based organisations prior to testing. Forty per cent of participants agreed that people who disclosed their HIV status were at risk of isolation from mosques/church. This belief was slightly more prevalent among those who attended services more frequently, but the difference was not statistically significant.

Religion and health-seeking behaviours and outcomes

Bivariate analysis found that there was no relationship between religiousness (as measured using frequency of attendance at religious services and religious attitudes or beliefs) and late diagnosis. There was also no relationship between religiousness and changes in CD4 cell count 6 months after diagnosis. Belief in healing or the importance of religion was not associated with starting antiretroviral therapy (75% of those who believed that taking medicines implied lack of faith had started antiretroviral therapy compared with 67.9% of those who did not; P = 0.954; data not shown) or viral load (at diagnosis or 6 months afterwards for those on antiretroviral therapy).

Discussion

The results of this cross-sectional study examining late diagnosis in Black Africans living in London indicate that strong religious beliefs about faith and healing do not act as a barrier to accessing HIV services or antiretroviral treatment. As expected for this population group, religion and expression of religious belief through service attendance were very important to most of the participants. Given the importance of religion, it follows that a large proportion of participants indicated that they believed in the power of healing through prayer, and suggested that ‘faith alone could heal HIV’. However, this belief in healing through faith was not translated into the perception that medication is unnecessary; only a small percentage of participants believed that taking antiretroviral therapy implied a lack of faith. Although it may seem contradictory to believe in a faith-based cure and yet still take man-made medicines, it seems that most individuals are able to reconcile their faith in the ability of God to heal HIV infection and the knowledge that they themselves will still need to take antiretroviral therapy to remain well.

This is supported by the finding that there was no significant difference in uptake of medication and CD4 and virological response between those with strong religious beliefs and those without. Although the belief that HIV infection can only be cured through prayer and that adherence to antiretroviral therapy represents a lack of faith exists, it is not widespread within African communities in London.

Previously published work shows that an important reason for Africans not testing for HIV earlier was low perception of personal risk [5]. It is possible that strong religious beliefs influence risk perception; however, this study has shown that only a very small proportion of participants had not tested earlier because they had believed that God would protect them from HIV, and religiousness was not associated with late presentation.

Although this study did not find an association between religiousness and HIV outcomes, the role of religion may be an important factor in the high degree of stigma associated with HIV in these communities. Previous research has shown that for some individuals, especially those attending African Pentecostal or charismatic churches, faith in God, and regular prayer in particular, may be perceived as insurance against ill-health and bad fortune [6, 7]. In such churches, infections like HIV, or perceived vices such as homosexuality and prostitution, are portrayed as demonic spirits that can possess and control an individual [6]. Churches engage in a type of ‘spiritual warfare’ and ask members to participate in a range of rituals designed to defeat the demonic spirit attacking an individual. Thus, through spiritual warfare, individuals can protect themselves from contracting – or indeed be healed of – HIV infection [6].

In these and other churches, those who are HIV positive may be seen as being punished for sins such as homosexuality or promiscuity, and HIV is considered a ‘curse from God’. Sex itself may be stigmatized as sinful and sexual sin considered the gravest of all the sins [8]. In some cases, the suffering of those living with HIV may even be inappropriately exalted as a virtue and seen as the unavoidable, preordained fate of an individual [8, 9]. These religious doctrines that relate to morality and social order can be problematic. They may lead to self-stigmatization of those living with HIV [10] or result in prejudicial attitudes from leaders and others within faith communities [11, 12].

While the findings here suggest that individuals from African communities do fear isolation from their place of worship after disclosing their HIV status, they also point health promotion experts to an underutilized resource in HIV prevention. Fewer than one in ten participants had received HIV/AIDS information from faith leaders or faith-based organizations prior to testing. Recent studies suggest that community-based HIV testing programmes that increase the opportunities for testing are feasible and acceptable to African communities [13]. Harnessing the solidarity of faith communities to increase uptake of HIV testing has been effective in a range of communities, from Africa to the USA [10, 14-16]. By encouraging faith communities in the UK to raise awareness of HIV testing, the number of African people living with undiagnosed HIV infection and the levels of late diagnosis could be reduced.

This survey is not without its limitations, which have been discussed elsewhere [5]. The results presented here do not explore the differences in attitudes and beliefs across religious denominations because of the small sample size. Rather, these results provide an overview of the attitudes and beliefs of those who practice their faith by regularly attending religious services. It is possible that with a larger sample size differences according to religious denomination could be found.

In March 2011, the National Institute of Health and Clinical Excellence released intervention guidance on increasing the uptake of HIV testing among Black Africans in England [17]. Evidence from this paper suggests that HIV prevention interventions utilizing faith communities could play an important role in interventions for Black African communities. However, further research is needed to determine the role of faith leaders in particular; while those attending mosques or churches might not focus on belief in God as a way to protect from or ‘cure’ HIV, care is needed before engaging in HIV prevention efforts that may ultimately do more harm than good. Additionally, the role of faith in the lives of people living with HIV should be explored qualitatively to provide a nuanced understanding of the tension between the spiritual beliefs in a cure and the medical knowledge that one has yet to be discovered.

Acknowledgements

The authors would like to thank all those who participated in the study and staff at all participating centres. The SONHIA collaboration group included: J. Ainsworth, North Middlesex University Hospital NHS Trust, G. Brook, North West London Hospitals NHS Trust, A. Fakoya, Newham University Hospital NHS Trust, J. Walsh, Imperial College Healthcare NHS Trust, E. Jungmann, Camden Primary Care Trust, C. Orkin, Barts and The London NHS Trust, and S. T. Sadiq, St George's, University of London.

Conflicts of interest: The authors have no conflict of interest to declare.

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