PAPER PUBLISHED AS: Trinitapoli, Jenny. 2006. "Religious Responses to Aids in Sub-Saharan Africa: An Examination of Religious Congregations in Rural Malawi." Review of Religious Research 47:253-270.

Jenny Trinitapoli Department of Sociology and Population Research Center University of Texas at Austin

Running Head: Religious Responses to AIDS

For helpful comments and advice, I thank Susan Watkins and Mark Regnerus. This research is supported by grants from the Andrew W. Mellon Foundation and the Society for the Scientific Study of Religion. Direct correspondence to the author at Population Research Center, University of Texas at Austin, 1 University Station G1800, Austin, TX 78712-1088 ([email protected]).

Religious Responses to AIDS in Sub-Saharan Africa: An examination of religious congregations in rural Malawi

ABSTRACT This study attempts to explore the role religion may play in HIV transmission by focusing on the place of religious organizations in shaping the HIV risk behavior of individual congregants and addresses the question: How are religious congregations responding to the AIDS crisis in subSaharan Africa? Examining the specific context of rural Malawi, this study addresses three aspects of the link between religious organizations and the AIDS epidemic: 1) the extent to which religious leaders discuss HIV and related issues in their churches and mosques, 2) church/mosque-based organizational structures of accountability that may emphasize social control and help curb risky behavior among members, and 3) the activities of religious congregations in response to the AIDS crisis. Analysis of qualitative data collected in 2004 reveals that religious leaders discuss HIV and related issues frequently and provides evidence that congregations in rural Malawi are responding to AIDS-related issues by participating in activities like caring for the sick, sponsoring AIDS education programs for youth, and emphasizing the care of orphans as a religious responsibility.

Across sub-Saharan Africa (SSA), as in much of the developing world, religious organizations have become key providers of care and support to people living with HIV/AIDS and of preventive education, in spite of the limited funds at their disposal (Liebowitz 2002; Pfeiffer 2002). Nonetheless, the role of religious organizations in HIV/AIDS risk in SSA has not yet been a topic of rigorous scholarly inquiry. This study attempts to further explore the role religion may play in HIV transmission by focusing on the role of religious organizations in both shaping thoughts and attitudes with regard to HIV and influencing HIV risk behavior, and asks the question: How are religious congregations responding to the AIDS crisis in SSA? This study addresses three aspects of the link between religious organizations and the AIDS epidemic in Malawi, a country in which 92% say they belong to a religious denomination, and where HIV prevalence is high, with about 14% of adults HIV positive. First, this study attempts to establish the extent to which religious leaders discuss HIV in their churches and mosques and to characterize messages individuals are likely to hear from their religious leaders. Second, recognizing the importance of social interactions for how individuals assess their own risk and initiate behavior change, this study identifies church/mosque-based organizational structures of accountability that may maximize social control and curb risky behavior among members. Third, this study documents what religious organizations are doing in response to the AIDS crisis, and in doing so addresses the controversial issue of stigma as well as helping behaviors and volunteerism. Many scholars have identified religious organizations as having the potential to be either partners in or obstacles to combating the HIV/AIDS epidemic (for illustrations of each view see, for example, Green 2003b; Hunter 2003). As the most common formal organizations in rural SSA, religious organizations could play a key role in mitigating the consequences of AIDS. On

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the other hand, anecdotal evidence suggests that some religious organizations consider one key approach of international HIV prevention programs, condom use, to be illicit, and that some stigmatize rather than support those with AIDS. Given the magnitude of the epidemic in SSA and the widespread participation of Africans in religious organizations, it is surprising that there has been so little systematic assessment of the extent to which, and the mechanisms by which, religious organizations in SSA facilitate or impede effective responses to the epidemic.

Religious Organizations and HIV in Sub-Saharan Africa In setting an agenda for the study of religious organizations in the United States, Chaves (2002) distinguishes between three distinct types of religious organizations: congregations, denominational organizations, and religious nonprofits. Religious congregations are defined as “relatively smallscale, local collectivities and organizations through which people routinely engage in religious activity: churches, synagogues, mosques, temples” (2002:1523). The term denominational organization is used to refer to non-congregational organizations that produce religion (Catholic diocese and mission organizations would belong in this category). Finally, religious nonprofits are those religious organizations working in nonreligious fields, such as hospitals, drug rehabilitation programs, schools, etc. In the context of the US, organizations like the YWCA and Catholic Charities would be considered religious nonprofits. Although Chaves’s typology is intended specifically for analyzing religious phenomena in the contemporary US, it is a useful and relevant tool for examining religious organizations in other parts of the world as well. Most existing studies that address the response of religious organizations to the AIDS crisis in this region focus on the impact of faith-based organizations (FBOs). Although

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references to FBOs often fail to precisely define the types of groups to which they refer, the term has primarily been used in reference to large nongovernmental organizations (NGOs) with religious affiliations (e.g.. World Vision, Save the Children), corresponding to Chaves’s religious nonprofit category. The work of FBOs in response to AIDS has received a great deal of attention from journalists and international aid workers but has seldom been the subject of rigorous evaluation or scholarly inquiry. In reviewing the work of FBOs in 53 African countries, Perry (2003) recognizes that these organizations have frequently been the objects of criticism, but emphasizes that in many communities they have been key providers of services ranging from intervention strategies designed to prevent the spread of HIV to palliative care for those in advanced stages of the disease. In addition to emphasizing the contributions FBOs have already made to combating AIDS in places like Uganda, Senegal, and Jamaica, Green (2003a) argues that FBOs are particularly well-positioned to promote fidelity and abstinence - behavior changes known to reduce HIV risk - throughout much of the developing world. Though to a lesser extent, denominational organizations have also been identified as important players in the fight against HIV in SSA. Hearn (2002) refers to Evangelical missions in Kenya as “invisible NGOs,” since research both on the growing NGO sector and on the evolution of African Christianity has overlooked their role in civil society. She argues that while the missions were largely silent during the early spread of HIV in Kenya, they began to see AIDS as an opportunity to promote their teachings on sexual behavior and respond to unmet needs, a technique that Hearn and others (e.g., Scott 1991; Stoll 1990) refer to as “disaster evangelism.”1 Green (2003a) has also identified the early dialogue established between government and religious leaders as one of the key factors in the successful stabilization of HIV

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The term disaster evangelism has most commonly been used in to refer to church responses to natural disasters (hurricanes, floods, earthquakes, etc.) and epidemics.

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seroprevalence rates in Senegal and Uganda and has argued that the early inclusion of denominational leaders in government-led efforts to combat the spread of HIV may be crucial to their success. For the most part, studies and commentaries on how religious organizations are responding to the AIDS crisis in SSA have focused primarily on religious nonprofits and denominational organizations. Congregations, the first and most immediate level of religious organization, have been largely overlooked in this literature. The vast majority of Africans are either Christian or Muslim, and levels of religious participation across SSA are high; over half attend religious services regularly (Barrett, Kurian, and Johnson 2001). Leaders at the congregational level have frequent contact with members; they are also highly esteemed and are among the most influential members of their communities (Pfeiffer 2004b). Still, in examining the response of religious organizations to HIV in this region, very few researchers have examined the religious organizations operating at the congregational level – the level of daily interaction for most Africans. Furthermore, existing studies that have examined the role of religious congregations provide discrepant characterizations of religious responses to the AIDS crisis in this region. While some highlight the important roles religious leaders play in responding to AIDS in their communities, others argue that religious leaders are largely silent on the issue and, thus, contribute to the worsening of the epidemic. At least three studies offer some evidence that religious leaders in parts of SSA are acting in response to the AIDS epidemic. Throughout his research in Mozambique, Pfeiffer (2004b) observed that religious leaders there do not talk about AIDS directly or by name, but refer to it as the “illness of the century.” According to Pfeiffer, leaders and lay people alike emphasize fidelity within marriage as the main strategy for preventing the spread of HIV. In fact, in

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describing the growth of AICs in Mozambique he observes that “sexual fidelity is a constant topic for sermons, groups discussions, and consultations with prophets” (Pfeiffer 2002: 184). However condoms are never mentioned openly (Pfeiffer 2004). The pastors Pfeiffer interviewed said that HIV positive members would be supported and treated well within their churches, and Pfeiffer saw evidence of church members providing material support (i.e. firewood and food) to individuals believed to be sick with AIDS and to their families. Documenting the role of religious leaders in promoting sexual behavior change in Nigeria, Orubuloye, Caldwell and Caldwell (1993) interviewed over 100 Christian and Muslim leaders identified through snowball sampling. They found that religious leaders were regularly addressing the dangers of HIV by encouraging their members to refrain from sexual relations outside of marriage. Christian leaders conveyed messages about the dangers of HIV through preaching and, less frequently, through personal discussion with church members. Muslim leaders, on the other hand, emphasized the importance of leading exemplary lives to serve as a model and conducting household visits in order to impart messages about HIV to individuals who may be at risk. Almost 75 percent of the Christian leaders interviewed said that they had intensified their preaching on issues of sexual morality in response to AIDS; many of the other 25 percent claimed to have always spoken out on these issues. In addition, over 80 percent of Muslim leaders interviewed said they saw themselves as having influential leadership over their followers. Surprisingly, about a third of the Muslim leaders in this study said that they would support campaigns that encouraged the use of condoms as a form of safer sex. In and of themselves, messages about HIV from religious leaders may or may not be effective in reducing risk behavior among members. Garner argues that Pentecostal religion, in particular, is protective against the spread of HIV because it provides a powerful discourse on the

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costs of risky behavior and creates a nearly all-encompassing social reference group for its members (Garner 2000). He suggests four key variables in religious organizations that may account for their power to shape congregants’ sexual behavior: (1) indoctrination, (2) fostering religious/subjective experiences, (3) exclusionary practices concerning non-members, and (4) socialization processes (e.g., channeling congregants toward more frequent and overlapping interactions). Garner observed that in KwaZulu Natal, non-Pentecostal congregations displayed less intensity and interest on each of these. Congregants belonging to these congregations were more likely to overlook church teachings on sexuality, and their church officers were less likely to attempt to control members’ sexual behavior. Not all scholars agree, however, that religious leaders have actually been responsive to the HIV epidemic. In examining the relationship between religion and HIV risk in rural Senegal, a country with one of the lowest HIV prevalence rates in all of Africa, Lagarde and colleagues (2000) argue that Christian and Muslim leaders in Senegal, have been only minimally involved in AIDS prevention. In 1999, they conducted interviews with two Muslim imams, one Lutheran minister and one Catholic priest and found that only the Protestant minister reported giving messages about prevention. The conclusions about religious leaders made by Lagarde and colleagues are based on a very small number of interviews; furthermore, the fact that they did not find significant relationships between religion and preventive behaviors among lay people at the individual level may not actually be a reliable indicator of the extent to which religious leaders are discussing HIV. Since their study, sources like the Los Angeles Times (Simmons 2001) and the News Hour with Jim Lehrer (Lazaro 2001, May 17) have reported that conservative Islamic leaders are discussing AIDS regularly in their mosques and supporting government-led HIV prevention efforts. Others, like Pisani (1999) and Preston-Whyte (1999), have identified

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religious leaders’ responses as the single biggest impediment to the success of HIV prevention efforts. A World Bank report (1997) has also described the role of churches as a primarily negative one. By opposing sex education, discouraging condom use and explaining AIDS as God's judgment on sins of sexual immorality, Christianity and Islam have both been portrayed as a liability for combating AIDS, and this sentiment pervades a great deal of the AIDS literature from the social sciences, from governmental and non-governmental organizations, and from popular media. To be sure, the religious landscape, the magnitude of the AIDS crisis, the level to which religious leaders respond to it, and the ways in which they do so varies widely across SSA. The discrepant characterization of religious responses to the AIDS crisis may be due in part to differences among national religious and socio-political contexts or to differences in HIV prevalence levels. National statistics on HIV prevalence are of modest use, since prevalence levels vary greatly within countries (especially between regions and between urban and rural areas). However, these estimates are helpful for providing basic broad comparisons between nations like Uganda, where prevalence was an estimated 5 percent in 2003 and Mozambique where prevalence is an estimated 15 percent nationally and exceeds 30 percent in some areas. Malawi Malawi is a religiously diverse country, its AIDS epidemic is typical of the rest of the region, and religious congregations are a central component of rural life. These factors make rural Malawi an ideal setting for examining the response of religious congregations to the AIDS crisis more closely. As is characteristic of the pandemic across most of SSA, the HIV epidemic in Malawi is a generalized one – that is, the spread of the disease occurs primarily through heterosexual transmission, the male to female infection ratio approximates 1:1, and perinatal

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transmission is common (Green 2003b). Malawi’s 1999 Sentinel Survey report of HIV prevalence estimates a national prevalence of approximately 15 percent, or 850,000 persons, the eighth highest country prevalence rate in the world. There is, however, wide variation across testing sites (from 2.9 percent to 35.5 percent), suggesting that some areas have been more successful in avoiding infection than others (National AIDS Commission 2003). The vast majority of Malawians are either Christian or Muslim. Figures for Malawi from the World Christian Encyclopedia (Barrett, Kurian, and Johnson 2001) suggest that 77 percent of the population is Christian, 15 percent Muslim, and most of the remainder practice traditional African religions (eight percent). Malawi differs only slightly from AIDS-belt countries in eastern and southern Africa in its proportion of Christians (e.g., 82 percent in Zambia, 83 percent in South Africa) but has a higher proportion of Muslims than most. The major Christian denominations as a percent of the total Christian population are Roman Catholics (25 percent), mission Protestants (20 percent), and African Independent Churches or AICs (17 percent); groups like evangelicals and Pentecostals are rapidly growing in Malawi, particularly in urban areas, and together account for about 32 percent of the country’s Christians (Jenkins 2002). The religious composition of Malawi’s rural areas differs somewhat from the national figures, with Muslims comprising a majority in the South and Mission Protestants being dominant in the North. This is the context of the following examination of religious congregations’ responses to a generalized AIDS epidemic in rural SSA. Data and Methods The data for this study come from a qualitative data collection project conducted in two districts of rural Malawi during the summer of 2004. The study was designed to complement the longitudinal survey data collected by the Malawi Diffusion and Ideational Change Project

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(MDICP)2 by providing in-depth information about the religious congregations that survey respondents of Rumphi and Balaka districts attend. The data were collected for two primary purposes: 1) to categorize unfamiliar religious congregations into denominational categories that meaningfully capture variation in the religious landscape of rural Malawi and 2) to create a baseline picture of how religious congregations are responding to the AIDS crisis in these two distinct rural areas. A census of religious organizations was conducted in the 60 randomly selected villages in two districts, from which the survey respondents were drawn (17 villages in Balaka where villages are large and 42 in Rumphi where villages are much smaller and the population is less dense). Some residents of these villages attend churches and mosques located outside of their own village (i.e., on the border with a neighboring village or at a nearby trading center); these churches and mosques were also included in the census (N=13). Over a period of two months, each congregation (N=85) was observed at least once during a main weekly service. Trained research assistants were instructed to observe3 and write reports on each congregation’s organizational structure, the service itself (with particular focus on the message of each service), and the congregation’s other activities. Some of the larger congregations were also observed during weekday activities like Madrassa, Bible study, fellowships, women’s groups, visiting the sick, and other service projects.4 The level of detail in the reports varied substantially depending on the individual research assistant. Some reports resemble quasiverbatim transcripts of the religious service in its entirety, complete with descriptions of the 2

Further details regarding the sample and methods of the MDICP as well as the data and codebooks, are at: http://malawi.pop.upenn.edu 3 Permission to attend the service was requested immediately prior to the service as specified in the IRB for this project. In all cases, religious leaders granted the research assistants permission to observe their services. Since permission was requested immediately before the start of the service, it is unlikely that the leaders substantially changed the messages or the content of the services with such little notice, though the messages and behavior within the congregation may have somewhat altered in response to the presence of “visitors.” 4 This was particularly true of the large Catholic mission in Balaka and several other large mosques in this area.

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setting and conversations overheard among members of the congregations before and after the service. Other reports are comprised of summary paragraphs describing the service in broad strokes. Each member of the research team wrote their report in English immediately following the service. In most cases, research assistants were experienced interviewers who had worked previously for the MDICP; all received additional training specific to this project and, to ensure comparability across reports, were instructed to cover certain topics in the written reports. These reports (N=116), along with a small number of informal, semi-structured interviews with key religious leaders (N=20), constitute the data for this study. [TABLE 1 ABOUT HERE] Table 1 provides an overview of the sermon report data itself, showing the types of congregations observed in each research site. A total of 54 distinct religious congregations were observed in Balaka district, and 31 congregations were observed in Rumphi district. As these data suggest, while there is a large Muslim presence in Balaka district (17 mosques in this area were included in the study) no mosques were observed in Northern region. Additional denominational differences between the two research sites will be examined in further detail in the results section of this paper. Like all data collection strategies, this methodology has advantages and disadvantages. Perhaps the clearest advantage is that these reports provide a summary from a perspective outside the congregation. The research assistants did not write reports on the congregations to which they themselves belonged, and in most cases they were visiting congregations outside of their own religious tradition. As outsiders, research assistants had no apparent incentive to present the congregation as “favorable” in particular ways. In contrast, had they been writing about the congregations they themselves attend, research assistants may have felt motivated to

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present their congregation in a positive light, believing that there may be rewards for doing so (e.g., funding from NGOs or mission organizations to continue good projects). Furthermore, as outsiders, the research assistants came to the subject with fresh eyes; many of reports describe in great detail the rites, rituals, and messages previously unfamiliar to the research assistants. Another important advantage is that these data do not only provide a record of what was said about AIDS in any given religious service, they also provide a sense of how much religious leaders talk about AIDS relative to other issues. Likewise, they present a picture of how much of the congregation’s weekly activities are devoted to AIDS-related issues (i.e., visiting the sick, caring for orphans, organizing an educational campaign) relative to other activities (i.e., evangelism, political activism). The methodology employed in this study also has its disadvantages. First, the information contained in these reports is difficult to quantify, which complicates making comparisons between the research sites and among denominations. Second, it is unlikely that the research assistants actually wrote down everything of interest that occurred during each service. Observations are necessarily filtered through the research assistants’ own experiences; events of interest may have been omitted – even systematically - but it is impossible to determine the extent of such omission. Third, since most congregations were visited only once, it is impossible to determine whether the services observed are typical of a religious service in this congregation or not. Despite these limitations, the data used for the present analyses are rich and of high quality. Several of the research assistants had been working as survey interviewers for the MDICP since 1998. These research assistants were experienced and personally committed to the study of HIV in Malawi; furthermore, many expressed genuine interest in visiting religious

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congregations other than their own and seeing the diversity of religious belief and practice within their country. While the research assistants knew that AIDS was a particular topic of interest, the data was collected with the broader aim of documenting organizational, doctrinal, and practical aspects of religious life in Malawi. Judging from the content of the reports, which vary widely, the research assistants wrote reports that give accurate accounts of the messages, practices, and activities of the congregations observed. I begin by providing brief description of each research site, paying particular attention to the religious and HIV/AIDS situation in each. I then present results from the data described above, which were analyzed using ATLAS.ti, a software package that allows the importation and coding of textual data, as well as the capacity to assist in identifying patterns. Results of these analyses are presented below in sections corresponding to the three aspects of the primary research question: How are religious congregations responding to the AIDS crisis in rural Malawi? Excerpts from the sermon reports that were chosen to be used here were included because they provide some of the most poignant examples of recurring themes. Results Research Sites: Religion and HIV in Rumphi and Balaka Balaka District is in the southern part of Malawi, follows a matrilineal system of kinship and lineage where residence is ideally matrilocal, meaning that women remain in their mothers’ households – or at least within the village – after reaching maturity, and their husbands come to live with her family after marriage, while sons leave their mother’s household when they marry. Balaka is primarily inhabited by Yao-speaking persons and is predominantly Muslim (66 percent). About 13 percent of Balaka residents identify themselves as Catholic, nine percent belong to Pentecostal-type churches, 8 percent to Mission Protestant denominations. The villages

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in Balaka District tend to be large and densely populated; most villages have between three and five churches or mosques, and some of the largest villages have as many as eight. Rates of attendance at religious services in Balaka are high (nearly 75 percent of Balaka residents attend church weekly, and only six percent report attending less than once a month) but not ubiquitous. Rumphi District, located in the northern region of the country, is inhabited primarily by Tumbuka-speaking persons who follow a patrilineal system of kinship and lineage. In Rumphi, residence is ideally patrilocal, inheritance is traced through sons, and parents of a groom pay “bride wealth” to parents of his bride. The district is located near Livingstonia, a Protestant mission established by the Free Church of Scotland in 1894, and the religious composition of the region provides some evidence of the persisting legacy of Protestant missions here. In Rumphi, mission Protestants – mostly members of the Church of Central Africa Presbyterian (CCAP) – make up the single largest religious group (30 percent), followed by Pentecostals (27 percent), who are more numerous here than in Balaka. Although many of these churches explicitly prohibit polygamy, the practice has strong roots among the Tumbuka and the patrilocal pattern of residence facilitates this practice. Most polygamous men belong to African Independent churches, many of which closely resemble the mission Protestant churches from which they split (often over this very issue). Over 60 percent of Rumphi residents attend religious services weekly or more often, and 11 percent report attending less than once a month. Most villages in Rumphi have one or two churches; however villages are relatively small, and while most residents attend church within their own village, it is not uncommon for people to affiliate with a church in a neighboring village. A 2003 report on national HIV prevalence estimated HIV prevalence in rural Malawi to be between 10 and 15 percent (National AIDS Commission 2003). According to district-level

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estimates based on sentinel surveillance data gathered in antenatal clinics, however, prevalence of HIV infection among adults in Rumphi was about eight percent, and in Balaka, about 19 percent.5 Compared to the male residents of Rumphi district, men in Balaka report higher levels of perceived risk for HIV; they also are more likely to report having had an extramarital partner during the past year and to report ever having had a sexually transmitted infection (Trinitapoli and Regnerus 2004). Prevalence and Type of Religious Messages about AIDS The first goal of this study is to establish the extent to which religious leaders discuss AIDS in their churches and mosques and to characterize the types of messages rural Malawians are likely to hear from their religious leaders. Based on observations at over 100 religious services, it is evident that religious leaders in rural Malawi talk about AIDS explicitly and frequently. Unlike in Mozambique, where pastors often talk about “illness,” but rarely mention AIDS by name (Pfeiffer 2004b), in both Rumphi and Balaka, religious leaders often name the disease to which they refer. In approximately thirty percent of the services that were observed, the leader made at one least direct reference to HIV or AIDS. Another 10 percent of these contained references to “illness” more generally, and these are likely to have been interpreted as references to AIDS.6

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Prevalence levels reported here were calculated using district-level estimates of the number of adults 15-49 infected with HIV in 2001 (reported in National AIDS Commission 2003) divided by the percentage of the district population age 15-49 from the 1998 Malawi Census. This method should provide a reliable (perhaps conservative) estimate, since Malawi's population is rising while its infection rate is believed to be relatively stable (overall). 6 As one reviewer pointed out, there are many endemic and devastating illnesses in SSA that were around long before AIDS, and we cannot be certain that such references to “illness” were automatically interpreted as meaning HIV by all members. However, at the end of the data collection period in both sites I conducted a focus group with the research assistants that had been writing the sermon reports. In both focus groups, the research assistants suggested that the general references to “illness” they observed in religious services were likely interpreted by parishioners as references to HIV. Furthermore, illnesses like malaria, TB, cholera, and cancer were occasionally referred to by name in the sermon reports, which suggests that “illness” was not used as a catch-phrase for nonAIDS-related diseases.

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Not surprisingly, in addition to discussing AIDS per se, abstinence and fidelity are frequently the topic of religious messages. In fact, themes of repentance and salvation were the only ones more common than messages regarding abstinence and fidelity, and it’s likely that in this context these messages are understood as being particularly important when death is all around. The connection between repentance and AIDS was sometimes made explicit in other sermons as well. In several instances, the sin of adultery was equated with murder, arguing that in the era of AIDS - the consequences of these two sins are the same. The murder of innocents, in particular the risk of infecting a faithful spouse with HIV, was emphasized as a particularly deplorable sin. And the possibility of orphaning one’s children was also frequently mentioned, as in this AIC church in Balaka: “The country is sour and the world has changed. You must change your behavior or we will all die, and who is going to take care of your children?” In addition to speaking about the issue themselves, some religious leaders invite other speakers to their churches and mosques in order to talk about AIDS even more directly. For example, at a Jumah prayer service observed one Friday in Balaka, an Imam had invited a Muslim physician to talk about AIDS to the men and women in this mosque at the close of the service. The doctor emphasized the importance of fidelity for being a good Muslim and for avoiding AIDS. He emphasized that since condoms are not an acceptable alternative for Muslims, they can only keep themselves safe by being faithful. The doctor explained that he believed polygamy to be protective against HIV (arguing that polygamous men are less likely to seek sexual partners outside of their family), but warned that a polygamous man who is not treating his wives equally (as prescribed by the Koran) may be at heightened risk. He explained that a wife ignored may understandably be tempted to find a “sugar daddy” and bring AIDS into the household, killing the husband and the other, innocent, wives as well.

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During another visit to a weekday youth service at a mission Protestant church in Rumphi, the pastor had invited a team of counselors from a national AIDS awareness organization to teach during this service; church elders had previously encouraged all the youth in the congregation not to miss this program and to bring their friends, “without considering what denomination they are.” A crowd of over 450 attended the program7, which emphasized the importance of abstaining to avoid unwanted pregnancy, HIV, and other STIs. The group conducted short skits illustrating consequences of having sex before you are “mentally, physically, and financially ready” that included: contracting HIV, dropping out of school (due to pregnancy), and even death during childbirth.8 An additional skit illustrated a “clever” and “goal-oriented” young woman who tries negotiating with her boyfriend, who wants to have sex, but finally leaves him, saying: “Goodbye. I wish you all the best during your girl campaign. Sex can wait, but my future can’t.” While messages about abstinence and fidelity were commonplace, as expected, condoms were mentioned only rarely in religious services. When condoms were mentioned, they were usually being explicitly prohibited, referred to as unacceptable, or described as promoting promiscuity.9 However opposition to condom use among religious leaders in rural Malawi is not monolithic. Several pastors, including this AIC pastor in Balaka district, have relaxed prohibitions against condom use: “The government is saying people should have condoms and I cannot preach against it because they have seen that the people cannot abstain. It is good for those that can manage to abstain. My members are free to use the condoms when ever they want

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On a normal Sunday, this congregation usually has about 80 people at their service, and about 25 youth usually attend the weekly youth meetings. 8 The story acted out told of a very young girl who became pregnant but died during childbirth since her body was not mature enough to safely deliver the child. 9 See Pfeiffer (2004a) for an excellent account of the Pentecostal church’s responses to condom social marketing in Mozambique.

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to but the message of God remains: ‘No Adultery!’” Another report, from a Pentecostal church in Rumphi, tells of a lay leader giving a similar message: “The lady continued that there are many ways of catching AIDS, but the best way is sex. She said that doing sex with a condom is not safe because it is not 100% safe. And she told the youth that you are young adults. There is no way for you to not be doing sex. So you are advised to be doing with condoms for the sake of early pregnant and catching HIV/AIDS. But let me warn you: you are not safe in the eyes of God because God hates premarital sex.” Religious messages about AIDS almost always connected the disease with sin. While some have argued that religious leaders promote the idea that AIDS is an individual punishment for sexual sin (World Bank 1997), religious leaders in rural Malawi articulate a more nuanced understanding of the relationship between sin and HIV. AIDS is often talked about as a collective scourge (Kaler 2004) that plagues the entire population in a response to generalized wickedness, and it is often interpreted as a sign of the “end times.” Most religious leaders recognize that in addition to adulterers, many “innocents,” (i.e., faithful spouses and children) are infected with HIV and that the disease is not an accurate indicator of sexual sin. In fact, during one sermon at a Baptist church in Balaka district, the pastor bemoaned the fact that two-thirds of the funeral cases of Christians he attends are associated with HIV. He emphasized that some, but not all of these, were adulterers and expressed his frustration that “the faith community keeps on decreasing in number.” In addition to directly discussing AIDS, many religious leaders also use allegory to teach about the disease. Stories, for example, warning men not to go eat nsima10 at the neighbor’s house if they do not like their wife’s “cooking” or telling of a wife who goes out to get “soap” for washing clothes from another man since her husband does not provide her with any, are met 10

Corn porridge – a staple food in Malawi.

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with nods and nervous laughter. Of all the religious leaders interviewed, only one (a Catholic priest) said that he does not talk about AIDS in his congregation: “I don’t make much noise about sex, but talk about morality. And when I talk about morality, I am implicitly talking about sex. And people know this. I’m not talking directly about sex and AIDS, but I am encouraging morality. Morality in all aspects of life.” More often, however, religious leaders reported talking about AIDS and sex “often,” “at least two times per month,” and “as often as I can.” Accountability Structures The second goal of this study involves identifying church/mosque-based organizational structures of accountability that may enhance social control and curb risky behavior among members. In analyzing the sermon reports, four such structures or practices were identified: visiting the sick, clergy home visits, promoting “non-genital” friendships among youth, and encouraging voluntary HIV testing before marriage. The practice of visiting the sick differs for Christians and Muslims but is central to religious life in rural Malawi for members of both traditions. Most congregations are relatively small; members live within walking or biking distance and tend to know each other well. The absence of regularly-attending members are noted, and each week a congregation-based committee organizes to visit these members. Committee members visit the sick, bringing gifts (e.g., corn, sugar, soap, or money) and often helping the ill with household tasks like fetching water, collecting firewood, or smearing their hut.11 The committee also visits “lazy Christians” (those who have not been attending but are not sick) to “chat,” “find out if there are other problems,”12 and encourage them to attend. The practice of visiting the sick and the “lazy

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Covering the hut with a fresh coat of mud to keep it strong and maintain its appearance and structural integrity. It is common for individuals experiencing extreme economic hardship not to attend because they are ashamed of their inability to give an offering. Traveling to attend the funeral of a friend or relative in another village is another common problem that keeps members from attending. In these cases, the committee visit is intended to bring

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Christians” creates a structure of accountability, where regular attendance is enforced rather effectively. On several occasions, research assistants overheard individuals mentioning that while they did not feel like walking all the way to church on a particular week, they did so because they did not want other members to fear that they were sick and come to visit.13 This practice serves to keep people involved in their congregations and in communication with their religious leaders. For Muslims, visits to the sick are carried out by the lay faithful, but the Imam is the one who visits “backsliding” Muslims who are not attending. These clergy home visits are another important accountability structure that religious congregations provide. Several Christian and Muslim leaders reported that individuals who suspect that their spouse is being unfaithful can talk to clergy about their suspicions, and they will visit and confront the straying partner. This strategy is most commonly employed by women who suspect or know of their husbands’ infidelities; however one clergy member also reported being asked by men to talk to their wives. Concerned friends and neighbors have also reportedly asked their religious leaders to make such visits to a friend or to the spouse of a friend. Finally, one Imam reported that he does speculating on his own, and visits households if he suspects that “things” (particularly infidelities) are going on. He also said that he makes himself present in the village – especially at the trading center, where Muslims may be tempted to buy beer or meet a casual or transactional sex partner. He believes that his presence deters wrongdoing and said that when members of his mosque see him at the trading center, they sometimes look like children who are about to do something wrong but stop when they look up and see their father watching them.

“cheer” to the grieving. Individuals who choose to work in their fields instead of attending church or mosque are considered greedy and are frowned upon. 13 It is worth noting that, in this context, “walking distance” often means hours, and in many villages, households are spread out and household visits involve a great deal of time and energy.

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Many religious leaders have identified youth as being at elevated risk for contracting HIV and have focused particular prevention messages toward this group. The promotion of “nongenital friendships” between men and women is a strategy that several religious leaders in Christian churches brought up in informal interviews, and it was also evident in some of the youth programs observed. Malawian society is strongly sex-segregated, and this is particularly true of rural areas. It is very rare to see men and women talking or interacting in almost any way outside of the home. In churches as well as in mosques, men and women almost always sit on opposite sides of the church. Courtship in Malawi varies markedly from Western standards; relationships are generally initiated when a man “proposes,” a woman accepts, and they go off to a private place, often to have sex (Poulin 2005). Outside of sexual and family relationships, men and women have very limited contact with one another. In fact, in Chichewa, the term chibwenzi (pl. zibwenzi), which means friend, is the same term used to refer to a romantic partner. It is commonly understood that when used in reference to a same-sex individual, chibwenzi means friend, and when used to refer to a member of the opposite sex, romantic involvement is implied. One Catholic priest asked the youth in his congregation if they had any friends of the opposite sex, and none of them did. “In Malawi, there is an idea that friends must sleep together, so the youth are being encouraged to discuss friendship and to find other definitions of friendship. In [other countries] men and women and boys and girls are more mixed, and they have friendships without having sexual relationships. The boys and girls need to talk and spend time together and think about friendship and think of it as something else that doesn’t have to involve sex.” In several other churches, youth meetings are revolving around the theme of “friendship” as well. In a mixed setting (unusual for this context) adolescent boys and girls are discussing what friendship is and what it is not. The goal of these is to promote the ideas that

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friendship does not require sexual involvement, that men and women can and should spend time together without becoming sexually involved. While this message is not unique to churches (NGOs and other AIDS prevention groups promote this message as well) churches provide a particularly effective setting for distributing this message. First, as evidenced through the youth program in Rumphi that drew a crowd of over 450, churches have the ability to reach a lot of people, including many adolescents who are not currently attending school. In addition, the meetings themselves serve as a type of “experiment” in which adolescent boys and girls interact platonically, often for the first time, in a supervised group setting. Finally, in rural Malawi, as in many other places (Lugalla et al. 2004), religious leaders across traditions are encouraging - and in rare cases even requiring - young people to get tested for HIV before their marriage can be blessed. Routinizing HIV testing in this way has important consequences. Of course, this practice has the potential to protect an uninfected individual from marrying someone who is found to be positive. In addition, requiring HIV tests among individuals who wish to marry creates a cohort of people who have been tested. This demystifies the testing process itself for the individuals being tested and for many of those around them and helps to erode the secrecy and stigma that is sometimes involved with seeking out an HIV test. Through these four practices, religious congregations provide unique structures of accountability that may influence the risk-behaviors of their members. The structures identified here serve to keep people involved in their congregations, provide a source of authoritative intervention when needed, monitor the behavior of members, promote non-sexual relationships among youth, and require the determination and disclosure of HIV status between partners before marriage.

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The AIDS-Related Activities of Religious Congregations The final goal of this paper is to document what religious organizations are doing in response to the AIDS crisis. As previous research suggests, the bulk of congregational work in response to AIDS involves caring for the sick, widows and widowers, and orphans. The analysis of reports from religious services in rural Malawi show that helping behaviors are extensive and generous, and that stigmatization of persons infected with HIV is rare. The practice of visiting the sick and the elderly is the single most common activity in which religious congregations in rural Malawi are engaged. In small congregations, the visiting committee will organize and visit the two or three members of their congregation who are ill. In larger congregations, and in congregations where many members are sick, the visiting committee is divided into teams of two or three and sent out to visit as many as eight sick individuals in a single day. At times they conduct their entire weekday service at the home of the sick individual, but normally the visit involves bringing gifts, helping with household tasks, offering prayers and some songs. The visiting committees depend upon their own resources to provide assistance to the sick and to bereaved families. During main weekly services, an additional collection separate from the customary tithe is sometimes taken specifically to help the needy members. Members contribute goods, such as maize, potatoes, flour, sugar, or soap, and money, but the members of the visiting committee provide most of the assistance that the sick and bereaved receive themselves. Each week, the visiting committees report to their congregations on their weekly activities. This excerpt from a Presbyterian church in Rumphi district illustrates: Now I want the congregation to hear from those of you who went to our beloved sister in the Lord who lost her husband two weeks ago. Two men and four women

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stood up and gave their reports as the church sent them. I asked one close to me as to what they did. They brought to her as they went to console her. To his reply he said that church gave her 400 [Malawi Kwacha] and a tin of maize and it is to those who are sent their share with the one visited the words of God. They don’t just go there and give money…The most important thing is the message from the Bible. The gift of 400 kwacha, equivalent to four US dollars, is a generous one. To illustrate, the total weekly offering (tithes) with 93 people attending at the same church that day amounted to 383.85 kwacha.14 Most rural congregations are poor, and visiting committees typically bring a more modest gift, such as a single can of maize or a packet of sugar. Pastors regularly encourage their members to keep caring for the sick and not to be stingy in helping them. In fact, failure to participate in these helping activities is socially sanctioned. Many religious leaders give messages that warn against such greed, telling, for example, about a man who fails to assist the sick or the orphans, and has no one to bury him when he dies. Although some have suggested that individuals with HIV may experience particularly harsh stigmatization from religious leaders, this did not appear to be the case among congregations in rural Malawi. In fact, in organizing visits to the sick, many religious leaders work actively to guard against this. This excerpt, describing the message from the leader of a visiting committee in Rumphi district, illustrates: [This week] the program includes visiting the deceased’s family, a certain elderly mother and two women and one man suffering from HIV/AIDS. She said that when going we have to carry something for our friends. She continued that they should not

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The figure 93 includes children, who would not tithe. However, compared to the collections taken at other rural congregations, the sum of this collection is a relatively large amount. In the observed congregations, collections range from 6 kw, in one desperately poor congregation, to about 1,300 kw in one congregation located near a main trading center. Most congregations received between 150 and 200 kw in tithes from their members each week.

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be selective on whom to visit because a friend with AIDS is still a friend, and she said that AIDS is a pandemic disease that anybody and anytime can catch AIDS. However she said that that doesn’t mean that anybody who has HIV/AIDS was practicing prostitutions but there are many ways and means of getting AIDS that we will not teach today because everybody already knows them…The lady said that when coming out of this church everybody should get me correct. “Have I said that those two friends suffering from HIV/AIDS were prostituted?” The whole congregation said “NO!” The importance of treating the sick, the elderly, and orphans with compassion is also a frequent topic in churches and mosques in rural Malawi. Approximately 30,000 Malawian children have lost either one or both parents, and many (perhaps all) of these children are being taken care of through kinship-based child-fostering systems. As documented by Case and colleagues (2004), there is mounting evidence of discrimination against orphans within households, and religious leaders express awareness of this problem as well. A report from one AIC church in Rumphi shows a pastor addressing this issue: “There are some members of the church who live with the orphans. They do treat the orphans badly in favoring their own children. Is this a Christian?” [the pastor] asked. They all remain silent… He also talked that there are members of the church who fail to take care of the HIV patients and yet they pretend to be Christians. “Their love is hypocrisy!” he shouted. Of course, the practice of visiting the sick is not exclusive to religious congregations. Many rural Malawians travel long distances to care for sick relatives nearly every week. Furthermore, not all of those visited are sick with AIDS. However, religious congregations have

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institutionalized the practice of visiting the sick as part of being a good Christian or a good Muslim and have done so in a unique way. By organizing visits from non-relatives, providing material assistance, emphasizing principles of non-discrimination, and exerting pressure on members to share in the burden of caring for the sick, religious congregations have become the key providers of assistance for people living with HIV in rural areas of Malawi. Discussion This analysis of reports on the messages and activities of religious congregations provides evidence that congregations in rural Malawi are responding to AIDS-related issues in several different ways. Some of these responses may have important implications for shaping the HIV risk behavior of individuals and should, therefore, be the subject of more rigorous inquiry. For example, it is clear from these analyses that religious leaders often discuss AIDS in their weekly services, that they refer to it both explicitly and implicitly, and that religious messages regarding the spread of HIV are focused on abstinence and fidelity. However the impact that this message has on individual behavior is still unclear. The internalization of messages promoting abstinence and fidelity may have both direct and indirect effects on HIV risk. Most obviously, by limiting the number of sexual partners, practicing abstinence and fidelity may directly reduce risk by reducing exposure to HIV. Some researchers have argued that that messages of abstinence and fidelity also reduce HIV risk indirectly by delaying age at first sex (Green 2003b). They maintain that delaying first sex – even briefly – can have considerable impact on overall HIV infection rates since it significantly reduces the time spent in the most risky period for infection. As Garner’s (2000) work suggests, congregations that offer religious messages about HIV alone may not have the capacity to influence their members’ sexual behavior, but congregations that are strong on several of the

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four characteristics he outlined may influence individual behavior in ways that protect against HIV transmission. For example, in congregations where messages of abstinence and fidelity are accompanied by other accountability structures that serve to encourage regular participation or emphasize the authority of clergy as an enforcer of sexual morality, members may be particularly likely to observe regulations on sexual behavior and may, therefore, experience a lower risk of contracting HIV. Connecting individual-level data on HIV risk behavior with congregationallevel data on congregational leadership, organizational structure, doctrine, and AIDS-related messages would be an important step toward determining whether or not religious messages about AIDS actually influence the risk behavior of their members and would help identify the conditions under which such messages may be most influential. The design of the Malawi Religion Project (MRP),15 which will be fielded in the summer of 2005, offers at least one example for social scientists interested in connecting individual-level data on HIV risk behavior to the organizational, doctrinal and congregational leadership of their churches and mosques of how to go about doing so. The MRP is conducting a survey of religious leaders in approximately 300 churches and mosques throughout rural Malawi; the sample of congregations was created by asking a random sample of individuals (from the MDICP) to name the religious congregations they attend. Every named congregation is being identified and included in the sample of congregations.16 By linking individual-level factors such as demographic characteristics, reported risk behavior, and even HIV status (based on biomarker data collected in 2004) to the characteristics of larger of religious communities and to the attitudes and behaviors of individual religious leaders, this data will allow for a more

15

“Religious Organizations, Local Norms, and HIV in Africa;” Susan Watkins, PI, University of Pennsylvania. National Institute of Child Health & Human Development; April 2005 – March 2008; RO1-HD050142-01. 16 This strategy, known as hypernetwork sampling, was also utilized by the National Congregations Study in the United States (Chaves et al. 1999) in conjunction with the General Social Survey (GSS).

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rigorous evaluation of the impact religious messages may be having on individuals with regard to their AIDS-related behaviors and attitudes. Recognizing that the level of involvement on the part of religious congregations in response to the AIDS crisis is extensive does not, in any way, imply that congregational approaches to HIV prevention should necessarily be embraced, that funding to combat AIDS should be re-directed to churches, or that the task of caring for the sick should be left to congregational visiting committees. However, I argue that in this region the role of religious organizations, and congregations in particular, in responding to the HIV epidemic should be carefully considered, measured, and evaluated. In many communities, clergy are key authority figures, and may be an untapped resource for working to combat the spread of HIV. Clergy members not currently requiring young people to get tested before marriage may, for example, be integrated into local VCT initiatives. Furthermore, several somewhat surprising statements from clergy even suggest that some religious leaders may be more flexible on issues like condoms than previous anecdotal evidence has suggested. Overall, however, religious leaders in rural Malawi promote conservative messages about sexual behavior and HIV risk. Many of these messages may not resonate well with many Westerners (scholars and NGO workers in particular), due in part to the negative associations we may have with groups that promote such conservative messages in our own countries (Pfeiffer 2004a). Such discomfort with conservative messages should not, however, be a basis for dismissing or excluding church movements from AIDS-related scientific inquiry. What matters is whether conservative messages resonate with rural Malawians at risk of AIDS, and while little research in this vein has been conducted, other MDICP qualitative data suggest that they do (Watkins 2004).

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Religious leaders and congregations in rural Malawi already appear to be active in doing what they do best. With regard to prevention, they are preaching about abstinence and fidelity regularly, and this is exactly the area in which they are likely to be the most effective. So far, however, no studies have permitted comparison across religious congregations by systematically interviewing the leaders of all congregations, even in one area. Therefore, the collection of new data, capable of assessing the roles of religious organizations in HIV prevention and AIDS mitigation in SSA, should be a high priority for researchers in this area. In particular, developing data sources that include observations from multiple levels (i.e., individual, congregation, village, district) and can be used to measure the impact of religious messages and religious context at the individual level will be particularly valuable to further developing this line of research. Finally, the findings regarding what congregations are doing in response to AIDS reported in this study challenge the common assertion that religious organizations are silent about AIDS, or that they stigmatize (either by discriminating against or abandoning) persons with AIDS. To be sure, the extent of stigmatizing attitudes and behaviors varies widely, and in no way does this study imply that religious organizations have played no part in cultivating or perpetuating negative attitudes towards individuals infected with HIV. Still, the present examination of religious congregations in rural Malawi revealed no evidence of such treatment. The question of stigma is an important one that should be a priority for future research in this area. Research addressing empirical questions regarding the extent to which stigmatization occurs, its various forms, the predictors of stigmatizing attitudes and behaviors, and the role of possible mitigating factors will make important contributions to the existing body of knowledge about the social consequences of AIDS in this region.

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REFERENCES Barrett, David B., George Thomas Kurian, and Todd M. Johnson. 2001. World Christian Encyclopedia: A Comparative Survey of Churches and Religions in the Modern World. New York: Oxford University Press. Case, Anne, Christina Paxson, and Joseph Ableidinger. 2004. "Orphans in Africa: Parental Death, Poverty, and School Enrollment." Demography 41:483-508. Chaves, Mark. 2002. "Religious Organizations: Data Resources and Research Opportunities." American Behavioral Scientist 45:1523-1549. Chaves, Mark, Mary Ellen Konieczny, Kraig Beyerlein, and Emily Barman. 1999. "The National Congregations Study: Background, Methods, and Selected Results." Journal for the Scientific Study of Religion 38:458-476. Garner, Robert C. 2000. "Safe Sects? Dynamic Religion and AIDS in South Africa." Journal of Modern African Studies 38: 41-69. Green, Edward C. 2003a. "Faith-Based Organizations: Contributions to HIV Prevention." USAID/Washington and The Synergy Project, TvT Associates, Washington DC. —. 2003b. Rethinking AIDS Prevention: Learning from Successes in Developing Countries. Westport, CT: Praeger Publishers. Hearn, Julie. 2002. "The 'Invisible' NGO: US Evangelical Missions in Kenya." Journal of Religion in Africa 32:32-60. Hunter, Susan S. 2003. Black Death: AIDS in Africa. New York: Palgrave Macmillan. Jenkins, Philip. 2002. The Next Christendom: The Rise of Global Christianity. New York: Oxford University Press. Kaler, Amy. 2004. "AIDS-Talk in Everyday Life: The Presence of HIV/AIDS in Men's Informal Conversation in Southern Malawi." Social Science & Medicine 59:285-297. Lazaro, Fred de Sam. 2001, May 17. "Senegal's Success." In The News Hour with Jim Lehrer, Washington, DC: PBS. Liebowitz, Jeremy. 2002. "The Impact of Faith-Based Organizations on HIV/AIDS Prevention and Mitigation in Africa." Health Economics and HIV/AIDS Research Division (HEARD): University of Natal, Retrieved September 30, 2004 (http://www.nu.ac.za/heard/papers/2002/FBOs%20paper_Dec02.pdf). Lugalla, Joe, Maria Emmelin, Aldin Mutembei, Mwiru Sima, Gideon Kwesigabo, Japhet Killewo, and Lars Dahlgren. 2004. "Social, Cultural and Sexual Behavioral Determinants of Observed Decline in HIV Infection Trends: Lessons from the Kagera Region, Tanzania." Social science & medicine 59:185-198. National AIDS Commission. 2003. "Estimating National HIV Prevalence in Malawi from Sentinel Surveillance Data: Technical Report." Lilongwe, Malawi: POLICY Project, Retrieved October 1, 2004 (http://www.policyproject.com/pubs/countryreports/MALNatEst2003.doc). Orubuloye, I.O., John C. Caldwell, and Pat Caldwell. 1993. "The Role of Religious Leaders in Changing Sexual Behaviour in Southwest Nigeria in an Era of AIDS." Health Transition Review 3:93-104. Parry, Susan. 2003. "Responses of the Faith-Based Organizations to HIV/AIDS in Sub Saharan Africa." World Council of Churches/EHAIA, Retrieved (http://www.wcccoe.org/wcc/what/mission/fba-hiv-aids.pdf).

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Pfeiffer, J. 2002. "African Independent Churches in Mozambique: Healing the Afflictions of Inequality." Medical Anthropology Quarterly 16:176-99. —. 2004a. "Condom Social Marketing, Pentecostalism, and Structural Adjustment in Mozambique: A Clash of AIDS Prevention Messages." Medical Anthropology Quarterly 18:77-103. Pfeiffer, James. 2004b. "Civil Society, NGOs, and the Holy Spirit in Mozambique." Human Organization 63:359-372. Pisani, Elizabeth. 1999. "Acting Early to Prevent AIDS: The Case of Senegal." Joint United National Program for HIV/AIDS, Geneva. Poulin, Michelle. 2005. "Giving and Getting: Rethinking Sex, Money, and Agency among Youth in Rural Malawi." Paper presented at the Princeton Institute for International and Regional Studies Graduate Student Conference, Princeton, NJ, April 8-9, 2005. Preston-Whyte, Elenor. 1999. "Reproductive Health and the Condom Dilemma: Identifying Situational Barriers to HIV Protection in South Africa." Pp. 139-155 in Resistance to Behavioral Change to Reduce HIV/AIDS Infection in Predominantly Heterosexual Epidemics in Third World Countries, edited by J. C. Caldwell. Canberra: Health Transition Center. Scott, Luis "Lindy". 1991. Salt of the Earth: A Socio-Political History of Mexico City Evangelical Protestants (1964-1991). Mexico City: Editorial Kyrios. Simmons, Ann M. 2001. "In AIDS-ravaged Africa, Senegal is a beacon of hope." Los Angeles Times, March 9, A1. Stoll, David. 1990. Is Latin America Turning Protestant?: The politics of Evangelical growth. Berkeley: University of California Press. Trinitapoli, Jenny and Mark Regnerus. 2004. "Religious Involvement and HIV Risk: Initial Results from a Panel Study of Rural Malawians." Paper presented at the Population Association of America Annual Meeting, Philadelphia, PA, March 31- April 2, 2004. Watkins, Susan Cotts. 2004. "Navigating the AIDS Epidemic in Rural Malawi." Population and Development Review 30:673-705. World Bank. 1997. Confronting AIDS: Public Priorities in a Global Epidemic. Oxford: Oxford University Press.

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Table 1: Description of Sermon Report Data by District and Denomination

Catholic Quadriya Muslim Sukuti Muslim CCAP Baptist Anglican Pentecostal Seventh Day Adventist Jehovah's Witness African Independent Church Just Christian Church of Christ Other Total

BALAKA Congregations Reports 1 7 11 12 6 9 2 3 5 6 3 3 8 8 2 3 2 3 7 7 4 4 2 2 1 1 54 68

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RUMPHI Congregations Reports 2 3 0 0 0 0 3 8 0 0 0 0 7 13 4 4 0 0 8 12 0 0 5 6 2 2 31 48