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Strings AttachedAIDS and the Rise of Transnational Connections in Africa$

Nadine Beckmann, Alessandro Gusman, and Catrine Shroff

Print publication date: 2014

Print ISBN-13: 9780197265680

Published to British Academy Scholarship Online: January 2015

DOI: 10.5871/bacad/9780197265680.001.0001

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Transnational Religious Networks Encounter Community Realities

Transnational Religious Networks Encounter Community Realities

HIV Prevention in Zambia1

(p.107) 6 Transnational Religious Networks Encounter Community Realities
Strings Attached

Amy S. Patterson

British Academy

Abstract and Keywords

This chapter analyses the disjuncture between the Abstinence and Be Faithful (AB) programmes of HIV prevention supported by many transnational FBOs and funded by PEPFAR, and the implementation of those programmes in urban Zambia. While AB messages are conveyed to some sub-populations, they are noticeably absent among Zambian support groups for people living with HIV, groups that have increasingly become involved in HIV prevention. This disconnect results from different understandings of prevention, assumptions about personal responsibility and autonomy in sexual choices, local groups’ desire to develop non-prevention programmes, and the need for poverty reduction among many Zambians. The multiple layers of policy implementation evident in a programme like PEPFAR created space for these nuanced interpretations, demonstrating how local organisations may exhibit power in their relations with donors.

Keywords:   HIV prevention, abstinence, be faithful, PEPFAR, Zambia, faith-based organisations, poverty, sexual autonomy

Transnational Religious Networks Encounter Community RealitiesHIV Prevention in Zambia1

AIDS education poster along major thoroughfare in Lusaka, Zambia, 2011 (photo by author).

(p.108) IN 2003, US PRESIDENT GEORGE W. BUSH announced the President’s Emergency Plan for AIDS Relief (PEPFAR), which provided roughly $15 billion for HIV/AIDS programmes, primarily for sub-Saharan Africa. In its prevention efforts, it emphasised sexual abstinence and relationship fidelity (or ‘Be Faithful’) (hereafter referred to as AB). International faith-based organisations (FBOs) such as World Vision, Samaritan’s Purse, Compassion International, and Catholic Relief Services that receive grants from PEPFAR have emphasised these AB messages as part of their HIV/AIDS programmes in Africa. Yet scholars know little about how these messages have been implemented in African communities. This chapter investigates that dynamic, by examining how pastors, community HIV/AIDS workers, and local populations in poor, urban communities in Zambia, a country with an HIV prevalence of roughly 14 per cent, have incorporated the AB message into their HIV/AIDS responses (Ministry of Health, National AIDS Council and UNAIDS 2011).2 This chapter argues that there is a gap between PEPFAR’s emphasis on AB prevention messages and the actual HIV prevention activities in Zambia’s poorest communities. The work asserts that this ‘AB disconnect’ reflects the complexity of transnational governmentality and it is shaped by the extraversion strategies of African actors.

The examination of the AB disconnect in Zambia has both theoretical and policy relevance. On the theoretical side, the chapter elucidates the complicated relationship between donors and local partners. The conventional wisdom is that donors dictate policies to local partners, who implement such policies because they depend on external actors for their survival.3 Yet, relations between external actors and local players are dynamic, and African partners are not always passive recipients. They may reinterpret externally derived policies within social contexts, emphasising new elements and downplaying others. The chapter provides a picture of the complexity and fluidity in such relations. Such a nuanced understanding also has the potential to contribute to richer, more effective policies that take into account cultural, economic and political dynamics and that acknowledge the ways that local actors utilise their dependence on external ties to gain resources and power.

The argument proceeds in the following five sections. First, I describe my methodology. Second, I highlight two theoretical concepts that inform the work: transnational governmentality (Ferguson and Gupta 2002) and extraversion (Bayart 1993, 2000). Third, I examine the role of transnational FBOs in HIV/AIDS policy making, particularly the formulation of PEPFAR’s AB requirements. I argue that these requirements reflect Western ideals of individual agency and rationality as well as evangelical Christian beliefs that religious conversion can lead to moral behaviour that will alleviate social problems. I also assert that transnational (p.109) governmentality has emerged in the HIV/AIDS field, with Western donors channelling money to local partners for policy implementation. Fourth, I examine reasons that AB messages are not fully embraced at the grassroots level in Zambia. In doing so, I demonstrate how extraversion, transnational governmentality, and Zambians’ disillusionment with development explain gaps in implementation. Finally, the conclusion returns to the two theoretical concepts to raise questions for future research.


In order to analyse the multiple layers of transnational governmentality that shape the AB disconnect, I investigate the views of transnational actors, Zambian agents who acted as intermediaries between transnational and local organisations, and grassroots organisations. For the transnational perspective, I interviewed FBO representatives and policy makers in Zambia and the United States during 2005, 2007 and 2011, and I examined documents and websites for several transnational FBOs. Interview questions sought to discern FBO participation in HIV/AIDS efforts, relations between FBOs and local partners, and support for and implementation of AB prevention messages. I also conducted roughly fifty interviews during 2007 and 2011 with such intermediary agents as Zambian pastors, HIV/ AIDS educators, clinic officers, HIV/AIDS counsellors, and FBO officers. All of these individuals have some training on HIV/AIDS, and they interacted with representatives of transnational FBOs more directly than local community members did.

At the local level, I conducted focus group discussions with over fifty churchbased and secular HIV/AIDS support groups in urban Zambia in 2011. Church groups were linked to mainline and Pentecostal Protestant churches, while secular groups were affiliated with the Network of Zambian People Living with HIV (NZP+). I include both church and secular groups because their community programmes are similar and because secular groups also tend to stress Christian messages (Patterson 2011b). This research concentrated on urban areas because donors in Zambia have focused their HIV/AIDS efforts in the cities, and because the urban HIV rate (20 per cent) is twice as high as the rural HIV rate (Ministry of Health, National AIDS Council and UNAIDS 2011). Many of these support groups are composed solely of people living with HIV (PLHIVs), though church-based groups often include HIV-negative members such as caregivers. Because research has demonstrated that small group discussions about HIV have more effect on behaviour change than larger media campaigns (Li et al. 2009), donors have increasingly turned to groups of PLHIVs to spread prevention messages through ‘prevention with positives’ programmes (Ministry of Health, National AIDS Council and UNAIDS 2011). Focus group discussions examined the tangible and (p.110) intangible benefits of group membership, group activities, relations with donors, and group challenges. All interviewees were assured that their names would not be included in any written documents.

Transnational governmentality and opportunities for extraversion

Neoliberalism has transformed governmentality (or the multiple ways that human conduct is overseen), so that the state has ceded large areas of social policy to other actors including local organisations (such as churches and community-based organisations) and transnational actors (such as transnational FBOs) (van de Walle 2001; Ferguson and Gupta 2002). In this process, transnational actors and local organisations become partners in the development enterprise. Yet, the nature of these partnerships is complicated: on one hand, they reflect inequalities and hierarchies since the transnational organisation often has financial resources that the partner in the global South wants and/or needs. On the other hand, local organisations often have a degree of autonomy because they provide manpower, an entrée into the community, and broader legitimacy for the external partners. In so doing, they validate local participation in the broader development enterprise (Ellis 2011).

Local actors also may have autonomy in this partnership because transnational governmentality is administered through multiple levels of organisational command (Ferguson 1990). This long chain provides opportunities for players at any level to reinterpret policies and to emphasise some aspects of programmes over others. Multi-billion dollar programmes such as PEPFAR become ‘large, unsupervised spaces’ in which local groups can insert their own understandings of problems and solutions.4 For example, World Vision, a Christian relief and development organisation that employs roughly 22,000 people worldwide and has an annual budget of almost $1 billion, receives multi-million dollar grants for HIV/AIDS programmes from the US government. Grants are channelled from the international headquarters in the United States to particular countries (such as Zambia), where local staff members then select Zambian FBOs with whom to work. These FBOs, in turn, often partner with churches in rural villages or urban communities (Varsalona 2008). Despite the fact that World Vision International may have specific objectives when it applies for PEPFAR funding, by the time PEPFAR money trickles down to the community level, those programme goals may change or become more nuanced.5

Transnational governmentality heightens the opportunity for local African partners to engage in the strategy of extraversion, or playing up the continent’s (p.111) poverty and dependence to mobilise resources. In the case of HIV/AIDS, the external environment provides many financial opportunities since donors dispersed $6.9 billion in HIV/AIDS money in 2011 (PBS 2011).6 Access to these funds brings local actors opportunities for capacity building, workshop participation, incomegenerating projects, and sometimes, employment. As HIV/AIDS programme funding has increased, local partners have emphasised the disease at the expense of other development problems (Morfit 2011).

Three aspects of the extraversion concept are relevant in this context of high levels of funding for HIV/AIDS. First, as local actors ‘skilfully exploit’ their situations of dependence, they may use different types of rhetoric to appeal to Western audiences (Bayart 1993: 25–6). For example, they may emphasise the neoliberal assumption that markets will eradicate poverty and empower individuals: ‘We need markets for our goods, markets with people like you.’7 Or they may focus on religious rhetoric, including conservative views of sexuality or examples of spiritual devotion (Patterson 2011a). Such messages appeal to American evangelical churches, which have increasingly been involved in health and development issues in Africa (Hearn 2002).

Second, extraversion demonstrates the autonomy of African players in transnational governmentality. Local actors’ framing of issues or their use of particular rhetoric demonstrates their conscious engagement with the external environment. African actors are not victims, despite the continent’s relatively weak position in global economic and political structures. African players may even contribute to the design of institutions that advance their dependence. For example, several African experts on HIV/AIDS and African pastors gave the Bush administration input on the PEPFAR proposal, with a few African pastors, American conservatives, and some FBOs urging an emphasis on abstinence even as public health experts doubted the evidence that abstinence alone can lower HIV prevalence.8 Many of these African participants then benefited from PEPFAR since their organisations received funding.

Third, extraversion becomes a resource some, though not all, African players can use to centralise their power and accumulate resources (Bayart 1993: 21–4). Through extraversion, relations between the West and Africa become privatised, benefiting select groups instead of the public good (Bayart 2000). Actors with access to external resources may rise in status, wealth, and political voice. Two Zambian organisations provide examples. First, the Churches Health Association of Zambia (CHAZ) had received roughly $120 million by 2011 for its HIV-related (p.112) programmes from the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund 2011),9 resources that helped to increase CHAZ’s voice in health policy making. Second, the Northmead Assembly of God and the Gospel Outreach Ministries (Go Centre), two Pentecostal mega-churches in Zambia, started antiretroviral treatment (ART) and HIV testing centres through PEPFAR grants. External connections with World Vision also led pastors of these two Pentecostal organisations to found the Expanded Church Response Trust, which also gained PEPFAR funding in 2008. Partly as a result of these activities, the pastor of the Northmead church was named chair of the National AIDS Council (Patterson 2011a). External connections increased opportunities for greater resources and representation, though not for all local organisations.

The local organisations examined in this chapter have little direct control over the HIV/AIDS policies or structures of donor governments or transnational FBOs. Yet because of the open spaces embedded in transnational governmentality, local players can interpret HIV prevention in ways that may differ from external partners. At times, their engagement with the larger HIV/AIDS discourse looks like weakness, while at other times, they appear to resist the narrow AB focus of PEPFAR. Yet, unlike the hidden transcripts of resistance that James Scott (1990) analyses, these actions do not appear to challenge the hegemonic structures of donor-financed HIV/AIDS programmes. Because these structures have the potential to bring power and financial resources, local actors often find ways to work within their confines.

Transnational governmentality and the AB message

PEPFAR reflects the multiple layers of transnational governmentality: it was developed by a relatively small number of actors within the White House, National Institutes of Health, the US Senate, and select evangelical Christian organisations, and its funds have been dispersed to a wide variety of US government bureaucracies, non-governmental organisations (NGOs), FBOs, and select African ministries of health. These FBOs, NGOs and US bureaucracies, in turn, channel money to local African organisations. This section analyses the official AB policy at two of these levels – the policy-making level and the highest level of implementation.

By the new millennium, evangelical Christians in the United States had become an increasingly vocal constituency on foreign policy issues such as human trafficking and debt relief, though their influence on foreign policy is often overstated (Hertzke 2004; Wuthnow 2009; see also Obbo, Chapter 2, and Schoepf, Chapter 2, this volume). FBOs such as World Vision, Catholic Relief Services and Christian (p.113) World Service, with long histories in development, lobbied for PEPFAR’s passage, and they were joined by FBOs with more recent interest in development which sought greater access to government grants (den Dulk and Rozell 2011). The PEPFAR final legislation allocated 55 per cent of funds to treatment, 15 per cent to care and support of PLHIVs, 10 per cent to programmes for orphans and vulnerable children (OVCs), and 20 per cent to HIV prevention. Lobbying by FBOs and evangelical advocacy groups led to the requirement that 33 per cent of this prevention money be used for AB messages (Patterson 2006). Because mother-tochild transmission, blood safety, and safe medical use programmes are also included in prevention, programmes to stop sexual transmission of HIV received roughly 50 per cent of all prevention money. In 2005, PEPFAR recipient country teams spent 66 per cent of their sexual transmission prevention funds on AB activities, with the remaining sexual transmission funds going for HIV testing and condom distribution (Dietrich 2007). When the US Congress re-authorised PEPFAR in 2008, it changed the requirement so that 50 per cent of funding for prevention of sexual transmission of HIV must be spent on AB programmes in countries with generalised epidemics. The 2008 law continues to emphasise AB programmes, to restrict condom distribution to individuals 15 years of age and older, and to require that programmes that discuss condom use also discuss AB. In contrast, programmes that focus on A or B do not have to include discussion of condoms (Dietrich 2007; CHANGE 2011).

Three assumptions helped mobilise American evangelical Christians to support PEPFAR. First, Africans living with HIV/AIDS were often perceived to be innocent victims. This picture contrasted with the religious condemnation that PLHIVs in the United States (who were primarily gay men and intravenous drug users) experienced during the 1980s (Beckley and Koch 2002). Because most HIV infections in Africa resulted from heterosexual relations and mother-to-child transmission and because women make up the majority of HIV-positive Africans, evangelicals felt more comfortable addressing HIV/AIDS in Africa than in the United States (Christianity Today, 1 February 2006). As a result, FBO programmes often focused on women who were presumed to have been infected by promiscuous husbands and children who were infected in utero, during labour, or through breastfeeding. The ‘Be Faithful’ message emerged from this belief that innocent women (and their children) must be protected from philandering partners.

Second, evangelicals perceived fighting HIV/AIDS to include more than technical public health solutions such as increased HIV testing or condom distribution. Rather, they believed that the spread of the gospel should accompany technical solutions; they thought that religious adherents with sufficient faith and church support would change their sexual behaviour to limit HIV transmission. According to this view, youth should be urged to abstain from pre-marital sex, and they should receive support for such actions through church youth groups or abstinence clubs. Instead of condom distribution, HIV prevention programmes (p.114) should stress the sacredness of marital fidelity and the need for holiness in sexual decisions. For conservative American evangelicals, condom use in pre-marital and extra-marital relations defeated God’s plan for monogamy in marriage (Dobson 2000). Condoms were seen as a sign of spiritual defeat to worldly pressures.10

A video available during autumn 2011 on the website of Samaritan’s Purse, a transnational FBO based in the United States, illustrates this link between spiritual salvation and HIV prevention. It begins with the statement that 40 per cent of Ugandan women are HIV-positive, with most being infected by their husbands. It then tells the story of a husband who drinks too much beer and beats his wife, but quits this behaviour when both he and his wife become ‘born again’ in Christ. Religious conversion gives the husband the strength to abstain from sex outside of marriage, to quit abusing his wife, and to limit his drinking (Samaritan’s Purse 2008). In so doing, he does not bring HIV into the marriage.

Third, evangelicals tended to situate HIV/AIDS in the context of a highly personalised faith which revolves around the individual’s relationship with Christ. Because of this focus on individualism, American evangelicals have paid limited attention to the socio-economic structures that can condition individual behaviour and limit personal autonomy (Emerson and Smith 2000; Rah 2009). One result is the belief that people can utilise information to measure the physical, emotional and spiritual ramifications of their actions. In the context of HIV/AIDS, this would mean that individuals avoid sex before marriage, sex with older partners, sex with multiple partners, and/or sex with sex workers because these actions increase the risk of HIV infection (Fenio 2009). The perspective does not emphasise the cultural or socio-economic factors that might push people to engage in such risky behaviour.

Once the AB requirement was written into PEPFAR, transnational FBOs crafted programmes to meet this policy. To be clear, not all FBOs adopted a strict AB focus. For example, the ecumenical World Council of Churches (2006) states:

Successful HIV prevention programmes utilise all approaches known to be effective, not implementing one or a few select actions in isolation. These include promoting sexual abstinence, fidelity among married couples and the use of condoms for those who are not in a position to abstain or be faithful.

However, because PEPFAR favoured AB messages, many health and development NGOs and FBOs either had to adopt those messages or face challenges in gaining US funding. Transnational FBOs specialised in AB programmes, with 88 per cent of funding for FBOs in 2005 going specifically for AB efforts (Oomman et al. 2008). Four examples provide evidence of the AB focus among transnational FBOs:

  • Samaritan’s Purse, a relief and development organisation that started in 1970 and has been led by Billy Graham’s son Frank Graham since 1978, holds (p.115) workshop sessions based on Biblical principles with practical topics such as: HIV/AIDS basic facts, marital faithfulness, home care programmes, reducing discrimination, and overcoming the fear of testing’ (Samaritan’s Purse 2011).

  • Serving in Mission, a century-old organisation of evangelical missionaries which works in twenty-seven African countries, trains peer educators in several African countries (including Zambia) to lead ‘Life Skills’ courses that emphasise abstinence in schools. The goal of these courses is for ‘young people [to] hear from other young people how to live in a wise and Godly way’ (Serving in Mission 2011; see also Cooper 2006).

  • World Vision, which received $8.5 million for its work in Zambia between 2004 and 2008, stresses abstinence education. In 2005, World Vision Zambia trained thirty FBOs to run abstinence-only programmes, and it reached over 25,000 youth with these messages. With its 10- to 14-year-old participants, it talks about the importance of future faithfulness in marriage, while it gives general AB messages to participants in the 15- to 24-year-old group (Varsalona 2008).11

  • The True Love Waits campaign promotes AB in conjunction with Christian conversion in several southern African countries. From 2007 to 2011, ‘More than 1.6 million young people in Africa heard the True Love Waits message promoting sexual abstinence until marriage […] nearly 46,000 married adults have committed to faithfulness, and more than 41,600 [individuals decided] to follow Jesus Christ’ (True Love Waits International 2011).

Transnational FBOs either developed or increased their AB programming in response to PEPFAR’s AB policies. But transnational governmentality provides multiple layers for policy implementation and local actors can utilise those layers as sites of extraversion. I turn now to the Zambia case to investigate this possibility.

The reality of AB messages in Zambia

Zambia provides a context with multiple opportunities for religiously based strategies of extraversion, because of its large Christian majority and its access to high levels of HIV/AIDS funding. Eighty-five per cent of Zambians are Christian (Ranger 2008), and church organisations have considerable sway in society and politics.12 As evidence of the institutional capacity of church-based health institutions, Zambia was the first country to designate a non-state actor to be a principal recipient of Global Fund money (CHAZ was the organisation) (Patterson 2011a). Many Zambian FBOs are linked to transnational FBOs, and the country (p.116) hosts a large number of transnational FBOs.13 Finally, because of Zambia’s high HIV rate, the country has received large sums of external HIV/AIDS funding. As of 2006, donors funded approximately 77 per cent of the country’s HIV/AIDS response. Between 2003 and 2010, the country received thirteen HIV-related grants from the Global Fund and almost $1 billion from PEPFAR (Patterson and Stephens 2012).

HIV/AIDS programmes in Zambia are set within a context of a forty-year decline in the country’s development and the stark rise in urban poverty, economic factors that push local agents to reach for external connections to survive. Upon its independence in 1964, Zambia was a highly urbanised country with modern mining towns in the Copperbelt and industrial jobs that paid good wages. State officials, external policy makers, and citizens touted what James Ferguson (1999) terms the ‘myth of modernisation’, or the optimistic expectation that the country would inevitably reach urban, modern life within a generation. Yet, between 1974 and 1990, the country’s economy shrank 50 per cent because of declining copper prices and high external debt. Privatisation, cuts in state employment, and austerity measures exacerbated poverty, so that 64 per cent of Zambians lived in poverty by 2009 (Ferguson 1999: 10; UNDP 2011). Despite the country’s economic growth in the new millennium, urban poverty remains extremely high. By 2004, 70 per cent of the Lusaka population lived in shanty compounds and 70 per cent worked in the informal sector. For urban residents, the monthly cost of food was more than double the average monthly household income (Resnick 2011).

Given the country’s embeddedness in HIV/AIDS transnational governmentality and its work with a large number of American FBOs, one can certainly find evidence that AB messages are taught in Zambia. For example, the STEPS-OVC programme aims to provide HIV prevention information and behaviour change skills to 80,000 HIV-negative and HIV-positive people in Zambia.14 One way the programme does this is by training parents and youth to discuss sex openly together and by urging churches to facilitate these discussions.15 Yet such examples seemed unusual in community-level HIV/AIDS programmes. Below I first provide evidence from the focus groups, intermediary informants, empirical cases, and written reports for this lack of attention to AB messages. While the evidence is not comprehensive, it is from a wide variety of sources and it demonstrates a pattern. Then I analyse (p.117) four reasons for this disconnect, situating my explanations in the context of transnational governmentality, extraversion, and Zambians’ disillusionment with development.

The limited focus on AB messages at the community level

When questioned about their HIV/AIDS activities in the community, groups of PLHIVs rarely emphasised prevention of any type. Instead, members of both church-based and secular groups commented that they ‘go into the community to sensitise people’.16 Loosely defined, sensitisation included making people aware that HIV/AIDS is dangerous, discouraging community members from discriminating against PLHIVs, conducting voluntary counselling and testing (VCT), and approaching neighbours who appeared to be sick to urge them to get an HIV test.17 In all the groups I interviewed, no one specifically mentioned AB messages as part of these community sensitisation efforts. Church-based groups were less likely to refer to any type of HIV sensitisation and more likely to emphasise home-based care programmes for PLHIVs and OVCs than secular groups were.

Many pastors, church HIV/AIDS workers, and clinic counsellors confirmed these observations. One Pentecostal pastor said that one of the biggest problems in addressing HIV/AIDS in Zambia is the silence around sex in religious communities and among highly educated individuals.18 This silence limits discussion of AB messages. An HIV/AIDS programme director in a Pentecostal church bemoaned the fact that there is no discussion about sex in the churches or at home. As a result, youth were confused about how they should behave: ‘No one wants to talk about sex with kids. It is against our cultural experiences. But we have to. It is the only way.’19

On the other hand, there were some pastors and officers at church-based clinics who discussed prevention of sexual transmission of HIV, though they did not always focus exclusively on AB messages. At times this led to contradictions within the same organisation. For example, one Pentecostal pastor said, ‘We [the church] are about abstinence. While other places may talk about condoms, they [condoms] are not for us.’20 Likewise, a counsellor at that same church’s HIV/AIDS clinic emphasised the message of fidelity and sexual purity in a Christian devotion period with clinic clients.21 Yet, another clinic counsellor admitted that she discusses (p.118) abstinence, fidelity, and condom use with clients who receive an HIV test, regardless of the outcome of the test.22 And clinic social workers seemed pragmatic about how unequal power relations between Zambian men and women and the lack of individual agency among many poor Zambians made AB implementation difficult.23

Both extraversion and transnational governmentality can explain these contradictory messages. The pastor and counsellor may have emphasised AB in their interviews and public discussions because Western audiences most interested in church-based HIV/AIDS work might expect such an answer. Since this clinic receives numerous visitors from US churches, these public statements may not have been that unusual. To gain resources for their programmes, local actors may signal to their transnational partners that they share the external actor’s perspective. For example, Zambian pastors often stressed that the country needed spiritual rebirth, a return to moral behaviour, and ‘holiness’. HIV prevention through abstinence was just a small component of these larger messages.24 Yet, the fact that HIV/AIDS policies are governed at multiple layers provided ‘wiggle room’ for local players such as the clinic staff to tailor prevention messages to their clients’ situations.

Several churches that have HIV/AIDS programmes also seemed to downplay AB promotion. Many Zambian churches excelled in home-based care efforts: the Catholic diocese of Ndola alone served over 25,000 PLHIVs in 2009. But prevention messages were incorporated less frequently into many of these parishlevel church HIV/AIDS programmes (Fikansa 2009). In another example, a Pentecostal church in Chingola had worked on OVC care programmes since 2002. With money from transnational FBOs, the church provided food, school fees, and mentoring help to over 400 OVCs in the area. Yet, the church had few formal programmes to discuss AB messages with these youth, as the following exchange between my informant and the pastor illustrates.

Informant: So, some of the children you have been taking care of for years are now to the point where they are interested in the opposite sex. What are you doing for them for prevention?

Pastor: We have a programme to teach them particularly about child abuse and HIV and AIDS. And their rights. Because there are some homes where you can find children being abused.25 (p.119) The pastor defined HIV prevention primarily as prevention of child abuse, not as programmes that teach youth to abstain from pre-marital sex or to remain sexually faithful in their relationships. While child abuse is one means of HIV transmission (particularly between older men and adolescent girls), the pastor’s answer did not acknowledge youth sexuality. The example illustrates how local actors who receive funding from transnational FBOs but who are distant from policy makers may interpret issues in ways more contextually relevant. In this case, the pastor’s decision to focus on prevention of child abuse not youth sexuality may have been pragmatic and culturally situated because it did not necessitate difficult discussions about sex between youth and adults.

Public health officials, transnational FBOs, and academics working in Zambia also provide evidence that AB messages have not been fully embraced at the local level. The Ministry of Health, National AIDS Council and UNAIDS (2011: i) report that there was need in Zambia for greater attention to prevention messages, particularly those that address multiple and concurrent partners, transactional and inter-generational sex, and sex within discordant couples (these issues would partially be covered in AB messages). Along this vein, officials of transnational FBOs comment that the biggest challenge in addressing HIV/AIDS in Zambia is exposing people to prevention messages, and particularly youth to abstinenceonly programmes.26 Finally, an academic study of HIV/AIDS efforts in southern Zambia revealed that while organisations such as the Adventist Development and Relief Agency and the Catholic Church had official abstinence policies, they were not always ‘successfully promoted’. And because there was a general resignation in society to the fact that men tend to have extra-marital affairs, fidelity messages gained little traction (Byron et al. 2006: 16).

While AB messages are apparent in the rhetoric and programmatic goals of transnational FBOs (many of whom have received large sums of PEPFAR money), there is a disconnect between these high-level objectives and community actions in urban Zambia. Often groups of HIV-positive people (who have been urged to act as HIV prevention ambassadors) do not focus on these messages, and church members are uncomfortable discussing sexuality, particularly with youth. I now turn to an analysis of why the AB messages supported by many transnational FBOs and their political advocates in Washington, DC have not been fully embraced at the local level.

(p.120) Analysing the low priority of AB messages at the community level

The first reason for the AB disconnect is the different definitions of prevention that transnational FBOs and local HIV/AIDS activists emphasised. Transnational FBOs (and their advocates in Washington, DC) stress prevention of sexual transmission of HIV through abstinence and fidelity. This view reflects transnational religious actors’ focus on individual agency, Christian morality, and evangelism as tools to promote behaviour change.27 In contrast, community HIV/AIDS workers in Zambia describe prevention as sharing information on the disease and encouraging HIV testing. Almost all Zambian groups stressed ‘going into the community to urge HIV testing’.28

The country’s incorporation into HIV/AIDS transnational governmentality helps explain why Zambians emphasise HIV testing in prevention. PEPFAR set specific goals for the number of individuals it aimed to put on ART medications by 2008. These goals gave donors an impetus to quickly enrol HIV-positive individuals in free ART programmes after 2004. To place people on ART, though, they needed to be tested. One community worker explained that donors used all types of incentives to urge people to get tested, to disclose their HIV status, and to join support groups (these incentives included free food supplements and incomegenerating projects for support groups). The process led community HIV/AIDS groups to emphasise HIV testing over other prevention messages.29 During community meetings, HIV-positive individuals testified that ART had brought them back from the brink of death; they were now ‘fit and fine looking’.30 While inspirational, such stories drew attention away from AB strategies in HIV prevention to the promotion of HIV testing. Because the availability of ART meant that a positive HIV test was no longer a death sentence, some informants said Zambians had become complacent about HIV prevention.31

A perverse logic about HIV prevention emerged, illustrating how high-level policies can change grassroots dynamics and have unanticipated consequences. In terms of the AB message, because HIV testing (with a positive HIV test result) led to resources, community mobilisation has focused on prevention through testing not prevention of sexual transmission through abstinence, fidelity, or (p.121) condom use.32 More broadly, if HIV-positive individuals can access food supplements, project monies, and free medical care, there is little incentive for poor individuals to embrace prevention messages at all. Thus, while the ART rollout had positive outcomes – by 2011, 70 per cent of HIV-positive Zambians who needed ART medications could access them and ART was readily available in urban areas – it meant the prevention discourse focused on testing not AB messages (Ministry of Health, National AIDS Council and UNAIDS 2011).33

Second, the AB discourse collided with the ways that Zambian PLHIVs frame their experiences with the HIV virus. Their descriptions challenged the Western public health model of public disclosure and the evangelical emphasis on spiritual rebirth and testimony. Western donors and HIV/AIDS activists have put a premium on HIV-positive individuals telling their stories, even to the point that those who publicly disclose can gain financially. These programmes emphasise disclosure of one’s status and honesty about the risky sexual behaviour that led to infection (Nguyen 2010). Similarly, evangelical Christians often emphasise the role of conversion testimonies that describe how rebirth in Christ ends a life of sin (Ranger 2008). AB programmes sponsored by transnational, evangelical FBOs often include opportunities for participants to testify about how Christ’s forgiveness for their past actions had given them the strength to change their sexual behaviour. Such models of public disclosure faced challenges in Zambia.

In one sense, Zambian PLHIVs were quite detailed about their lives with HIV. They described their illnesses, physical reactions to ART medications, and their experiences with stigma and discrimination.34 But their stories of HIV infection often showed their lack of autonomy and/or downplayed personal responsibility. Some PLHIVs had no power over the actions that led to their HIV infection: they had experienced rape, spousal abuse, gender-based violence, child abuse, and unequal economic situations that made them reliant on abusive partners. These were all situations in which individuals lacked autonomy, regardless of their personal desire for sexual morality or their Christian faith (Siplon and Novotny 2007). Thus messages that emphasised choice or responsibility in sexual behaviour did not resonate with these individuals, and these PLHIVs did not emphasise such themes when they discussed HIV prevention.

Other PLHIVs with the financial resources and education to give them some autonomy did not emphasise responsibility. They did not talk about how their sexual behaviour (such as multiple partners, sex before marriage, and/or sex without a condom with a non-regular partner) may have contributed to their HIV infection. (p.122) For example, a spokeswoman for a church-related home-based care programme explained that she ‘could have been born with it [the HIV virus]’.35 While biologically possible, the woman’s age (she was roughly 60 years old) made this seem unlikely. A pastor in a mainline church described ‘turning from a past life’ after his HIV test, though he was never explicit about what his past life entailed.36

The unwillingness to engage in public disclosure and provide testimony on one’s HIV transmission is culturally situated, since Zambians sought to preserve status hierarchies and maintain community and family ties (Nguyen 2010). For example, one middle-class, educated HIV-positive woman explained that some women she knew could never disclose their sero-status publicly because poor Zambians would then look at them with disdain.37 Silence helped to preserve their position in society. Disclosure also brought potential negative ramifications for family relations: one NZP+ activist explained that when he publicly disclosed his HIV status his family disowned him. He laughed when he explained that once he became an activist and had access to external donor resources and unique opportunities, his family welcomed him back.38 If HIV disclosure is potentially destructive for family relationships, overt discussions of how one acquired HIV would be even more harmful (Nguyen 2010).

Because transnational governmentality provides layers for policy implementation, such culturally defined interpretations may emerge. Zambians used euphemisms to avoid direct discussions of sexual behaviour: sexual concurrency was described as ‘playing’ and one’s ‘past life’ referred to past risky behaviours. While clear to Zambians, the meanings of these phrases could be obscure to Westerners.39 Such murky terminology played a role in extraversion. It allowed local players to maintain access to external funding mechanisms while carefully framing sexual transmission of HIV in contextually relevant ways that downplayed the autonomy and personal responsibility themes embedded in AB messages. Many churches also participated in this vague discourse, mostly by limiting their discussion of sexual concurrency.40 One highly educated HIV-positive woman said that churches ‘were not doing enough’ on the issue of ‘playing’.41 In doing so, these churches have ignored the fact that sexual concurrency is a major driver of Zambia’s epidemic (Ministry of Health, National AIDS Council and UNAIDS 2011).

A third reason for the AB disconnect is that local players in HIV/AIDS transnational governmentality must respond to external processes in order to gain (p.123) and/or maintain access to resources. Some of these processes have not focused on HIV prevention. While such responses may appear to illustrate the impotence of local players, the fact that these groups both observe external trends in development and respond to them shows a certain level of agency. Yet, these actions have consequences, as two examples illustrate. In the first, the Northmead Assembly of God in Lusaka developed HIV/AIDS programmes in the late 1990s, which included VCT, a support group for PLHIVs, a school for OVCs, and HIV/AIDS awareness programmes that emphasised abstinence. As the church gained international media attention, it was able to lobby for PEPFAR money to establish an ART clinic. By 2011, the clinic served over 2,000 clients (Northmead Assembly of God 2011). To conform to donor and state-mandated requirements, the clinic hired professional nurses, clinical officers, counsellors, data entry specialists, and a programme manager. Yet these overworked and underpaid staff members had little time for community-level mobilisation on prevention.42 Also, the clinic-sponsored support group for PLHIVs concentrated its efforts on ART adherence messages and condom use among sero-discordant couples, not community-level AB prevention campaigns.43 The consequence of tailoring programmes to donor funding opportunities was a decline in attention to HIV prevention and an increase in attention to treatment and adherence.

The second example shows how local organisations responded to the demand among transnational NGOs and FBOs for empowerment and sustainability in HIV/AIDS programming.44 This trend emerged with PEPFAR’s 2008 reauthorisation and the decline in global HIV/AIDS funding that was sparked by the global recession in 2008 (PBS 2011). The financial situation increased competition among local FBOs, NGOs and CBOs (community-based organisations) for global HIV/AIDS money and it necessitated that these groups distinguish themselves in order to gain the attention of transnational groups. In response, one Pentecostal church began a rotating credit society and savings association for church and community members. This effort did not specifically target PLHIVs, caregivers, or OVCs, and the church emphasised that income was important for both people with HIV and people vulnerable to HIV infection. It received financial assistance from a Zambian FBO that had received money from PEPFAR.45 Even though it met PEPFAR’s focus on sustainable programmes, the church did not concentrate on AB prevention messages. (p.124) Strategies of extraversion allowed these two Zambian churches to gain external resources, but these strategies may empower some local actors while disadvantaging others. In the case of the clinic, professionalisation meant that the HIV-positive church members who had initially mobilised to establish the clinic did not get jobs at the clinic. With time, a board of health and business professionals governed the clinic and represented the church’s HIV/AIDS activities in the wider community. While extraversion brought resources, it empowered some Zambian professionals while it disempowered PLHIVs. Similarly, the ability of the Pentecostal church to get HIV/AIDS money for its rotating credit programme helped community members, though perhaps at the expense of using HIV/AIDS monies for people infected with or directly affected by the disease.

Finally, and perhaps most crucially, Zambians’ disillusionment with development has undermined the AB message, since this prevention message has not addressed the major concerns of most HIV-positive individuals and their HIVnegative neighbours. The discourse on sexual morality, with its roots in evangelical understandings of individual behaviour, clashes with the reality of life for many Zambians. In all focus group meetings with people infected with or affected by HIV, participants mentioned a ‘lack of food’ as a common problem they faced (Patterson 2011b). Participants discussed how their lack of income meant they could not send their children to school or pay for housing. One man detailed how he moved from place to place after his house was destroyed in a windstorm.46 Another father had no money to pay school fees and thus his son could not take the Grade 12 final exam for his high school diploma.47 And I lost count of the number of people who told me both formally and informally that they had not eaten anything in the last twenty-four hours. For Zambians infected with and affected by HIV/AIDS, prevention activities of any type were often a secondary priority.

However, this priority ranking could change, if sharing HIV prevention messages meant greater opportunities for material resources. Some HIV-positive Zambians gained positions as peer educators at community clinics, where they shared their experiences with clients and community members and urged prevention (though not always through direct AB messages). In return they received small stipends from the transnational NGOs or FBOs that funded these programmes. One man described how capitalising on his HIV status brought personal empowerment:

I started as a peer educator at a clinic, and then I was chosen to be an HIV counsellor. I was trained and did well. Then I eventually got this position as outreach coordinator for the NGO. I have a real job and am thinking of going to college now.48

(p.125) Extraversion strategies are evident in the man’s story: he utilised what outsiders often perceive to be a weakness (HIV positivity) as a resource to gain NGO employment. However, while it was possible for some PLHIVs to successfully use the extraversion strategy of sharing HIV prevention messages, the majority of PLHIVs (and their HIV-negative neighbours) did not consider HIV prevention efforts to be their biggest priority.

The rigid bureaucratic lines drawn in PEPFAR-funded programmes compounded this problem. For many transnational FBOs and NGOs, HIV prevention activities and economic support programmes for people infected with and affected by HIV are distinct. This delineation is evident in the separate coordinators, offices, and budget lines for each programme.49 This outcome resulted from the political bargains needed to gain support for PEPFAR from American conservative lawmakers, who saw individual-level sexual behaviour as distinct from social structures and who were sceptical of foreign aid. PEPFAR is results-oriented, focused on short-term solutions such as distributing ART medications and exposing people to HIV prevention messages. PEPFAR officials have tended to view economic support programmes or food distribution for PLHIVs as short-term solutions, not sustainable programmes.50 The fact that support, OVC care, prevention, and treatment all received distinct percentages of the PEPFAR budget solidified these divisions.

Yet, this policy delineation ignores how poverty can push individuals into sexual relations that make them vulnerable to HIV infection (Whiteside 2002). For example, abstinence-only education programmes for youth aged 14 to 24 may not acknowledge that many youth are already involved in sexual relationships that derive from their need to earn income. As one young HIV-positive woman argued, HIV infections are growing rapidly among youth in Zambia. This is partly because youth lack clear information about sexuality, and partly because youth seek economic opportunities, some of which may involve sexual relations with older men with income. In the informant’s opinion, for AB messages to resonate among Zambian youth the messages needed to be coupled with income-generation opportunities.51 This respondent did not distinguish between economic support and HIV prevention programmes. Because of the politically expedient programmatic divide in PEPFAR, HIV prevention efforts focused solely on sexual transmission often seemed irrelevant in poor Zambian communities.

In summary, through their different definitions of prevention, their indirect ways of discussing sexual responsibility, their response to new donor programme demands that drew attention from HIV prevention, and their emphasis on economic (p.126) support over AB messages, community HIV/AIDS groups sought to subtly shift the focus of externally designed prevention messages. In theory, local players did not disagree that sexual abstinence and marital fidelity were important prevention tools; rather, they just found these messages to be unrealistic or simplistic because they assumed socio-economic and cultural systems in which individuals have high levels of autonomy in their sexual choices. As one church HIV/AIDS worker explained: ‘You just can’t ask people to be perfect. They aren’t saints.’52


This chapter has analysed the disjuncture between the AB prevention programmes supported by many transnational FBOs and funded by PEPFAR and the implementation of those programmes in urban Zambia. PEPFAR’s requirement that a sizeable portion of money for the prevention of sexual transmission of HIV be spent on AB programmes gave transnational FBOs the opportunity to partner with local Zambian groups on AB efforts. While AB messages are conveyed in Zambia, they were noticeably absent among Zambian support groups for PLHIVs, groups that have increasingly been charged with prevention education. This AB disconnect results from different understandings of prevention, local groups’ desire to develop non-prevention programmes to meet donor’s demands, and the huge need for poverty reduction among many urban Zambians. AB models also faced challenges because of their assumption of personal responsibility in disclosure and autonomy in sexual choices. The multiple layers of policy implementation evident in a programme like PEPFAR created space for these nuanced interpretations.

The work raises two questions for future research. First, what are the conditions under which extraversion is most effective for gaining external financial support? Both secular and church-based support groups in Zambia stressed their poverty and dependence, and complained that they would be unable to continue their work without external funds. While most of these groups did lack capacity and resources, their emphasis on these themes highlighted their ability to play to Western assumptions, particularly the emphasis on charity-based development. Charitybased development is rooted in the idea that there is a hierarchy of deservedness, with women, children, and (often) HIV-positive people perceived to deserve more assistance than men, adults, or HIV-negative people (Siplon 2010). The expectation of Western charity was apparent when one HIV/AIDS group member said: ‘If we just had a well-wisher from abroad to help us, we would be okay.’53 How effective (p.127) is such rhetoric for gaining external resources? This research has not investigated how Western partners perceive such extraversion strategies. Yet, if extraversion implies a relationship between the African actor and the external player, more research is needed on how outsiders perceive extraversion strategies, including the use of particular rhetoric and imagery.

Finally, what are the implications of the gap between policy requirements in development programmes such as PEPFAR and their local interpretations and implementation? From the theoretical perspective, this divide challenges the conventional wisdom that foreign aid policies are imposed on poor countries. Scholars need to better understand how transnational linkages influence not only the making of development policies, but also their interpretation and implementation. From a practical angle, does this policy gap create confusion in HIV/ AIDS programming? And if so, what does that mean for local efforts to prevent HIV transmission? How might HIV prevention policies be changed so that local populations view them to be more culturally relevant or more responsive to the larger issues in their lives? This research demonstrates that HIV prevention policies that divorce poverty reduction from messages of sexual morality often do not resonate with poor urban Zambians. Because HIV prevention is essential to curb the HIV/AIDS epidemic in Africa, scholars and policy makers must pay greater attention to the disjuncture in official HIV prevention policies and their implementation on the ground.


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(1) Funding for this research was provided by the US Fulbright Africa Scholars Program, 2011. An earlier version of this chapter was presented at the conference of the Fertility and Reproduction Studies Group and the International Research Network on AIDS and Religion in Africa, Oxford, 28–30 September 2011. I am grateful for helpful comments from Ben Jones and the volume editors.

(2) To be clear, my interest in this issue does not revolve around the effectiveness of the AB strategy to limit HIV transmission or the individual-level decision to practise abstinence or fidelity.

(3) Interview, Zambian church HIV/AIDS coordinator, Lusaka, 16 August 2007.

(4) I am grateful to Ben Jones for this point and for sharing this phrase.

(5) Interview, US HIV/AIDS policy maker, Washington, DC, 15 April 2005.

(6) Despite this amount, many experts on HIV/AIDS do not think global funding for the disease is adequate (UNAIDS 2011).

(7) Interview, HIV/AIDS clinic support group, Lusaka, 9 April 2011.

(8) Interview, Zambian pastor, Lusaka, 14 August 2007; interview, Zambian pastor, Lusaka, 17 February 2011.

(9) CHAZ received roughly the same amount for malaria and tuberculosis programmes.

(10) Interview, transnational FBO representative, Washington, DC, 18 March 2005.

(11) Even though World Vision stressed AB messages in Zambia, it has engaged in condom education and distribution with at-risk groups in Vietnam (Varsalona 2008).

(12) Interview, World Council of Churches official, Lusaka, 7 August 2007.

(13) These organisations include International Justice Mission, Alliance for Children Everywhere, Christian Reformed World Relief Committee, Serving in Mission, Adventist Development and Relief Agency, Baptist Mission, Catholic Relief Services, and World Vision International.

(14) STEPS-OVC stands for Sustainability through Economic Strengthening, Prevention and Support for Orphans and Vulnerable Children, Youth and Other Vulnerable Populations. It is a consortium of seven NGOs, four of which are the FBOs Expanded Church Response, Salvation Army, World Vision, and Catholic Relief Services.

(15) Interview, Pentecostal church HIV/AIDS volunteer, Kitwe, 20 May 2011.

(16) Interview, NZP+ group, Lusaka, 22 March 2011; interview, NZP+ group, Lusaka, 23 March 2011; interview, Reformed Church group, Lusaka, 5 April 2011.

(17) Interview, NZP+ group, Lusaka, 12 April 2011.

(18) Interview, Pentecostal pastor, Ndola, 21 May 2011.

(19) Interview, Pentecostal church HIV/AIDS programme director, Kitwe, 20 May 2011.

(20) Interview, Pentecostal pastor, Lusaka, 17 August 2007.

(21) Observation by author, clinic devotions, Lusaka, 2 March 2011.

(22) Interview, clinic counsellor, Lusaka, 18 March 2011.

(23) Interview, clinic social workers, Lusaka, 1 March 2011.

(24) Observations by author, Northmead Assembly of God, Lusaka, 12 June 2011, and Miracle Life Church, Lusaka, 13 March 2011. See also Ranger (2008) for more on morality themes among African evangelical churches.

(25) Observation by author, Pentecostal church meeting, Chingola, 21 May 2011.

(26) Interview, transnational FBO official, Lusaka, 15 August 2007; interview, expert on HIV/AIDS, Lusaka, 31 May 2011.

(27) Most broadly, the term behaviour change is used to indicate any activities that prevent HIV infections. However, for religious groups involved with HIV prevention, behaviour change indicates not condom use, but abstinence and fidelity in relationships. Thus, when I refer to behaviour change in the context of these faith-based groups, I take their meaning.

(28) Interview, NZP+ group, Lusaka, 22 March 2011.

(29) Interview, NZP+ leader, Mumbwa, 15 April 2011.

(30) Interview, NZP+ group member, Kitwe, 19 May 2011.

(31) Interview, church HIV/AIDS expert, Lusaka, 31 May 2011; interview, clinic official, Lusaka, 7 June 2011.

(32) This logic in mobilisation has also led groups of HIV-negative individuals to lie about their serostatus in order to access resources. Interview, NZP+ coordinator, Ndola, 23 May 2011.

(33) Interview, transnational NGO official, Lusaka, 8 June 2011.

(34) Interview, member of NZP+ group, Lusaka, 23 March 2011; interview, member of church HIV/AIDS group, Lusaka, 11 April 2011.

(35) Interview, HIV-positive professional woman, Lusaka, 4 May 2011.

(36) Interview, Protestant pastor, Lusaka, 9 May 2011.

(37) HIV-positive professional woman, Lusaka, 10 May 2011.

(38) HIV/AIDS activist, Lusaka, 10 May 2011.

(39) expert on HIV/AIDS, Lusaka, 31 May 2011.

(40) Pentecostal pastor, Ndola, 21 May 2011; interview, Protestant HIV/AIDS coordinator, 10 May 2011; see also Chitando (2007).

(41) HIV-positive woman, Lusaka, 10 May 2011.

(42) Interview, clinical officer, Lusaka, 18 May 2011.

(43) Observations by author, clinic group meetings, Lusaka, 12 March 2011, 31 March 2011 and 26 May 2011.

(44) Interview, transnational FBO official, Lusaka, 13 April 2011; interview, transnational FBO official, Lusaka, 31 March 2011.

(45) Interview, members of church HIV/AIDS group, Chingola, 20 May 2011.

(46) Interview, HIV-positive man, Kitwe, 19 May 2011.

(47) Interview, HIV-positive man, Lusaka, 8 March 2011.

(48) Interview, HIV/AIDS coordinator with transnational NGO, Lusaka, 8 June 2011.

(49) Interview, transnational NGO official, Lusaka, 5 May 2011; interview, Zambian FBO official, Lusaka, 31 March 2011; interview, transnational FBO official, Lusaka, 31 March 2011.

(50) Interview, transnational FBO official, Lusaka, 31 March 2011.

(51) Interview, NZP+ youth group member, Mumbwa, 15 April 2011.

(52) Interview, Protestant church HIV/AIDS worker, Lusaka, 25 February 2011.

(53) Interview, NZP+ women’s group, Kitwe, 19 May 2011.