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In this article, Amy S. Patterson investigates how political power shapes the AIDS pandemic in Africa. Because Christians in the West often lack knowledge about how political power increases vulnerability to HIV infection and affects policy responses to the disease, the work analyzes the uneven impact of HIV/AIDS on countries, communities, and population groups. It investigates how power inequalities make some individuals more vulnerable to HIV infection and enable policy makers to reframe or ignore aspects of the pandemic. Further, power imbalances allow the powerful to exclude people affected by HIV/AIDS, at the expense ofChristian community, human dignity, and effective responses to the disease. The work incorporates four Christian principles—humans as created in God’s image, Christian community, humility, and a comparison of justice and charity—into its analysis. Ms. Patterson is Associate Professor of Political Science at Calvin College.

In 2005, the Joint United Nations Program on HIV/AIDS (UNAIDS) predicted that without continued large-scale commitment to fight the Acquired Immunodeficiency Syndrome (AIDS), 80 million Africans will die from the disease by 2025.1 While AIDS is a global problem, sub-Saharan Africa has been hit particularly hard. The region has over two-thirds of the world’s 33 million people infected with the Human Immunodeficiency Virus (HIV), the virus that causes AIDS. In 2007, 1.6 million Africans died from AIDS.2

Since the late 1980s, faith-based organizations (FBOs) and churches have developed AIDS programs in Africa. Many African churches, for example, designed home-based care programs for parishioners affected by HIV/AIDS.3 Similarly, international FBOs working on development issues have tackled AIDS prevention programs.4 Until recently, however, support for global AIDS efforts among American churchgoers was minimal. In 2002, Jeffrey Sheler reported that only 3 percent of American evangelicals were willing to contribute money to international AIDS prevention programs, compared to 8 percent of non-Christians. Similarly, while American evangelicals were twice as likely as non-Christians to support poor children overseas, they were less likely to support children orphaned by AIDS.5 These numbers changed after deliberate efforts to mobilize American Christians and increased media coverage of AIDS in Africa began in 2002.6 By 2005, majorities of evangelical and mainline Protestants, Catholics, Jews, Hispanic Protestants, and Black Protestants thought that “fighting AIDS” should be a U.S. foreign policy goal.7 In recent years, FBOs with AIDS programs increased their efforts, some FBOs started new programs, and American Christians lobbied for more AIDS funding. Scholars widely credit evangelicals with pressuring President George W. Bush in 2003 to develop the $15 billion U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), and they point to evangelicals’ continued interest in AIDS as one reason President Bush proposed doubling the program’s funds in fiscal year 2009.8 Many of PEPFAR’s accomplishments, such as increasing the number of HIV-positive Africans on AIDS treatment, have built on the experiences of FBOs and African churches in AIDS prevention, care, and support.

While Christ’s call to care for marginalized people motivates this advocacy and increased programmatic activity, James Guth, John Green, Lyman Kellstedt, and Corwin Smidt assert that high levels of Christian support for the AIDS fight may reflect the “newness” of the issue, and not an understanding of the topic’s religious complexity.9 Combating AIDS necessitates addressing issues of sexuality, cultural practices, and women’s position in society. Three factors have limited theAIDS efforts of Western Christians. First, citizens in the West lack knowledge about AIDS. A 2006 Kaiser Family Foundation survey found that 43 percent of Americans (and 32 percent of college graduates) held at least one misconception about how HIV is spread. Over half (55 percent) did not know that an HIV-positive pregnant woman can take drugs to reduce HIV infection in her baby.10 This relative ignorance contributes to the second limitation: an approach to AIDS rooted in idealism that ignores God’s created, but ultimately sinful, realm of power politics. Finally, often Christians have difficulty delineating justice from charity, viewing short-term AIDS efforts as facilitating justice, when ultimately these actions do not seek to change unequal structures in God’s world. As a Christian political scientist, I seek to tackle these three points through an analysis of some of the ways that power relations influence the pandemic.11 One goal of such research is to motivate and encourage greater and more enlightened Christian activism on the issue of AIDS. This analysis proceeds in four sections. First, I strive to address the first limitation: a lack of knowledge about AIDS in Africa. I outline the uneven impact of HIV/AIDS on countries, communities, and population groups, and the responses of African governments and international donors. Next, I explain four Christian principles that shape my analysis. Third, I define power and investigate how it influences the pandemic, in order to move beyond idealistic approaches to realistic responses to the pandemic. Finally, I analyze how Christian principles can inform our understanding of the power dynamics that shape AIDS politics. This last section provides suggestions on how Christian individuals and organizations can promote justice in the AIDS fight.

The AIDS Pandemic

Often the media, churches, and celebrities have portrayed all of Africa as under what Emmanuel Katongole terms the “AIDS blanket.”12 In reality, the pandemic has had diverse impacts on the continent, and there is wide variation in the percentage of people between 15 and 49 years old infected with HIV. In 2007,Botswana, Lesotho, Namibia, and Swaziland had HIV prevalence rates between 20 and 26 percent. In contrast, Senegal, Benin, Guinea, Mali, Niger, and Ghana had rates below 3 percent, while Central and East African countries had rates that ranged from 2.5 percent in Eritrea, to 5 percent in Kenya, to 8.7 percent in Tanzania.13

These statistics hide the uneven effects of AIDS at the community level. In Africa, HIV is spread predominantly through heterosexual contact and mother-to-child transmission during pregnancy, childbirth, or breastfeeding.14 In contrast to industrialized nations, where the majority of HIV-positive people are men, 61 percent of HIV-positive individuals in sub-Saharan Africa are women.15 Biology contributes to women’s vulnerability, since HIV can pass easily through vaginal membranes, especially those of young women. Women are seven times more likely than men to become infected during sexual intercourse with an infected partner.16 In addition, women’s lower economic and social status increases their risk of HIV infection. Women and girls often have less access to food in poor households. A 2007 study in Botswana and Swaziland demonstrated how gender-based food insecurity was correlated strongly with female engagement in risky sexual relations, such as forced sex, lack of control in a sexual relationship, and exchange of sex for food or money.17

HIV/AIDS affects children and young people disproportionately. An estimated 90 percent of the world’s 2.5 million HIV-positive children (defined as individuals less than 15 years old) live in sub-Saharan Africa.18 The primary means of childhood infection is mother-to-child transmission, though the number of infections through contaminated needles or sexual abuse is unknown. One study of 3,500 children in seven perinatal trials in sub-Saharan Africa found that without antiretroviral treatment (ARVs), 35 percent of HIV-positive children had died by age one and 53 percent had died before age two.19 The disease also harms children who are not HIV-positive, through the loss of parents, teachers, pastors, and mentors. In 2007, there were over 11 million African children under the age of 17 who had lost at least one parent to AIDS.20

While UNAIDS defines adults as individuals 15 years and older, recently the organization has begun to pay closer attention to the sexual behavior of young people aged 15 to 24. Half of all new HIV infections globally are within in this age group. This diverse population includes street children, young married females, and migrants, many of whom lack good information about HIV prevention. Reported declines in sexual activity among youth in Kenya, Malawi, and Zimbabwe hint that greater prevention education efforts in this group can be effective.21

Migrants are another population group that is vulnerable to HIV infection. Southern Africa has both high levels of migration and high HIV prevalence rates. Within southern African countries, areas with large migrant labor communities tend to have higher HIV prevalence rates than other regions. Economic necessity drives migration, since high unemployment rates and rural poverty often push young men to look for work far from home. With 5.5 million HIV-positive individuals in 2006, South Africa illustrates how migration can contribute to the spread of HIV. Thousands of rural black South Africans (and men from surrounding countries), who have little access to good land or economic opportunities, have traveled to work in the country’s gold and diamond mines. South Africa’s apartheid policies (in effect from 1948 to 1994) prohibited male workers from bringing their families to the mining communities. Over time, a culture of urban and rural wives and male identity situated around multiple sexual partners developed. Because health services in black villages and migrant communities were limited, sexually transmitted infections and tuberculosis (TB), diseases that increase a person’s risk of infection when exposed to HIV, often went untreated.22 Migration, poverty, poor health care, and social isolation fed the spread of HIV.

Refugees and internally displaced persons also face circumstances that can increase HIV vulnerability. According to the UN High Commissioner for Refugees, in 2005, more than 44 million people were displaced forcibly due to conflict, violence, or persecution based on race, religion, nationality, ethnicity, or political affiliation. Conflicts in Liberia, Sierra Leone, Côte d’Ivoire, Somalia, Uganda, the Democratic Republic of Congo, Zimbabwe, Sudan, and Kenya have increased the risk of HIV infection for those fleeing violence. The loss of livelihood makes sexual exploitation of women and children more likely. The use of rape as a tool of war and the breakdown of social norms that regulate sexual behavior heighten the risk of HIV infection further. Conflicts also disrupt health services, including HIV prevention and ARV treatment programs.23

HIV/AIDS has micro- and macro-level impacts on African societies. On the macro-level, one of the most apparent outcomes has been that life expectancy has declined to below 40 years in Botswana, Central African Republic, Lesotho, Malawi, Mozambique, Swaziland, Zambia, and Zimbabwe.24 This decrease has potential negative effects for African economies. On the micro-level, AIDS leads to a permanent loss of young, productive adults in a household; families sell assets to pay for food and medicine and they withdraw children from school because they cannot pay school fees.25 In 2003, a Human Rights Watch study of school attendance in Kenya illustrated that in such cases, families are more likely to pull girls from school than boys, a fact that highlights further how gender inequalities intertwine with the pandemic.26 Although there is often the assumption that households will cope with the disease, as they do drought or market downturns, many AIDS households do not recover from these losses.27 Yet, not all households are affected negatively; some may benefit from the disease, as the boon in coffin making for carpenters in highly affected countries illustrates.28

Since public health officials, national governments, international donors, and scholars became aware of AIDS in the mid-1980s, policy responses have vacillated. Few African leaders were willing to talk publicly about the disease until the late 1990s. The apartheid government in South Africa claimed that only “deviant” homosexuals and black African migrant workers from neighboring countries had the disease, not its own people.29 In 2000, South African President Thabo Mbeki emphasized the link between poverty and AIDS. While Mbeki tried to point out how poverty fosters malnutrition, economic migration, poor health, and food insecurity, all of which increase individual vulnerability to HIV infection, his statements questioned the scientific relationship between HIV and AIDS and they hampered AIDS education efforts.30 A 1998 World Council of Churches survey found that church leaders in many countries often refused to interact with those with AIDS.31 And despite U.S. intelligence reports outlining the growing pandemic, the Clinton Administration did little to develop new global AIDS programs throughout the 1990s.32 Funding was woefully inadequate; in 1998, for example, governments of AIDS-affected countries, bilateral donors, and multilateral organizations spent a total of only $479 million for AIDS programs in all low- and middle-income countries.33 To be fair, the U.S. Agency for International Development tried to mobilize African community organizations, including churches, to convey HIV prevention messages, and Family Health International sought to incorporate HIV prevention programs into its family planning programs. In Kenya, Medical Assistance Programs International launched an AIDS program in churches in 1994.34 In hindsight, however, these efforts and interest in the pandemic among Western policymakers were insufficient.35

Much has changed since 2001, when the UN General Assembly held a special session on HIV/AIDS and signed the Declaration of Commitment on HIV/AIDS. Funding has increased exponentially, from $1.3 billion in 2000 to $10 billion in 2007.36 In 2002, the global community formed the Global Fund to Fight AIDS, TB, and Malaria, a private-public entity that raises money and allocates grants to countries to address the three diseases. Since 2003, the Global Fund has committed $10 billion to projects in 136 countries. By fiscal year 2008, the U.S. Congress had allocated over $18 billion to AIDS prevention, care, support, and treatment programs through the President’s Emergency Plan for AIDS Relief (PEPFAR).37

Private AIDS initiatives have emerged too. Most international development organizations such as World Vision, CARE, Catholic Relief Services, and Jewish World Service have either begun AIDS programs or scaled up their previous efforts. The Gates Foundation provided $50 million for a model AIDS prevention-treatment program in Botswana, and it has given millions for research and control of TB and malaria, two diseases that hasten the deaths of HIV-positive individuals.38 Another effort is Product (RED)TM, which was introduced in 2006 by U2 singer Bono and politician/activist Bobby Shriver.39 Companies such as Armani, Gap,American Express, and Converse have developed RED products; a percentage of revenue from the sale of these goes directly to the Global Fund for AIDS projects.

These public and private efforts have had positive outcomes that should not be discounted. The number of HIV-positive Africans receiving life-sustaining ARV treatment has increased from approximately 3 percent of those who needed it in 2001 to 28 percent in late 2006. Since 2003, approximately 6 million pregnant mothers have received prenatal HIV testing and ARV prophylaxis to prevent mother-to-child transmission. Millions of HIV-positive people have received TB treatment through the Global Fund.40 Child-centered NGOs such as World Vision, Christian Children’s Fund, and CARE have provided food, shelter, education, and medical care to thousands of AIDS orphans. By mid-2007, Product (RED)TM had donated $25 million to the Global Fund, approximately 1 percent of Global Fund resources.41 While we Christians can celebrate these successes enthusiastically, we must not let powerful governments, their citizens, or ourselves believe we have conquered AIDS, since millions of people remain untouched by these policies.

Christian Principles and AIDS

Four overarching and interrelated Christian principles shape this analysis. Because the second deals with political community more specifically, I devote more attention to it. First, one of the central tenets of Christianity is that God created all human beings in his image and cares for them as unique individuals. Genesis 1:26 recounts: “Let us make man in our image, in our likeness,” while in Genesis 9:6, God explains to Noah the gravity of shedding the blood of another human because “in the image of God has God made man.” Because the physical body is a crucial part of the “economy of creation,” refusing access to health care to those who need it is a gross violation of the dignity and value of all people.42 The Creation story implies further that God cares about suffering and is present with people in their physical pain.43 The millions of HIV-positive Africans who lack sufficient medicine and food, and the millions who are at increased risk of HIV infection because of cultural, economic, and social structures, challenge these beliefs.

Of course, human beings are not defined merely by the physical body. God endowed all people with special gifts, stories, personalities, and experiences, and he made them complex creatures with emotional, spiritual, and social aspects. As Elias Bongmba asserts, HIV infection and suffering from AIDS cannot take away the person’s God-given dignity.44 All people have within them the “idea of transcendence,” which goes beyond the mind and body.45 The complexity of humanity necessitates that we understand poverty, development, health, and HIV/AIDS in multidimensional ways: the holistic nature of such issues requires attention to economic, social, psychological, physical, spiritual, and psychic elements.46

Second, God made people to live, work, and worship with one another. God himself is social, a “three-person community, radiant with love, joy, power, and beauty. Each person [in the Trinity] is God only with the other two.”47 Christians are called to be in relationships with co-workers, friends, family, spouses, congregants, neighbors, and other citizens. As Christians, “our identities are shaped in interaction with others and … we are called ultimately to belong together.”48 With our identities rooted in relationships with one another and the triune God, we are called to look not only to our own interests, but also to the interests of others. This view contrasts with Western liberalism which portrays individuals as autonomous actors whose identity does not derive from an outside power (such as God) or relations with others. Liberals assert that individuals with rights exist prior to the formation of society; people establish and participate in community because it protects their personal interests, not because it works to achieve a common goal.49 Paul cautions against such self-serving behavior, without discerning the effect on the larger body of Christ.50 To claim Christian discipleship necessitates that we love our brother whom we have not seen and work to build God’s beloved community.51 Despite geographic distance, Christians in the West must view Africans affected by HIV/AIDS as neighbors: “For the Christian, such a sense of obligation is constitutive of being part of the global community of faith.”52

As people called to live and work in community, Christians cannot avoid politics. Politics is the formal and informal processes by which individuals and/or groups allocate resources and make decisions. It includes not only activities in national legislatures or international institutions but also interactions within families, local organizations, and neighborhoods. Despite the fact that politics is often portrayed as “dirty,” God created political community, norms, and ideals and gave humans the ability to design political structures for making decisions about societal behavior or resources. While corrupted by sin, politics can be made new in Christ. Christians risk proclaiming “powerless love” at the expense of fostering greater justice in the AIDS fight, if they ignore political institutions that have legal resources, financial capacity, and issue experts. Since God is a God of action, and he utilizes human agency to work toward his plan in this world, Christians cannot shy from political activities such as advocacy, voting, and demanding government accountability in order to improve the lives of those affected by HIV/AIDS.53 Ezra Chitando, World Council of Churches HIV/AIDS Consultant, asserts that the pandemic needs a church “with a voice, one that will speak God’s truth.”54

Being part of such a community implies accountability and inclusion of all people. Because Christians are not autonomous, they are accountable to God and other humans. The Bible explains that believers are held responsible for disobeying God’s commands or ignoring the needs of his people.55 According to theologian Emmanuel Katongole, one tragic outcome of AIDS has been how it has perverted the relationship between Christians in Africa and the West even further: “The AIDS epidemic has pushed the negative characterization of Africa in the eyes of the West to its worst extreme. This suspicion, however, is being reciprocated by Africans, who increasingly are questioning Western goals and intentions.”56 As HIV/AIDS forces Africans to become “different people” in their behaviors, view-points, relationships, and identities, the church has the opportunity to provide alternative symbols and images.57 The message that Christian community values the participation of all individuals is an alternative to the social, spiritual, and political exclusion that people affected by HIV/AIDS often experience. For the church, inclusion means paying greater attention to discourse around AIDS: moving beyond blaming people affected by the disease to learning from and walking with them.58 Inclusion is the first step in restoring marginalized people into the community. Such restoration is crucial for the promotion of justice.59 Christ’s interactions with the adulterous woman, the blind beggar, the leper, Matthew and the other tax collectors, and the bleeding woman, for example, gave those excluded individuals voice and brought them into his new community.60 Building this new community is not easy, as Christ’s ultimate sacrifice illustrates. Emulating Christ’s servanthood requires time, patience, effort, and a willingness to challenge social conventions. In the context of AIDS, this process necessitates that Christians tackle difficult topics such as death and sexuality.61

Miroslav Volf uses the concept of “embrace” to symbolize the reciprocity and accountability of communal relations. For mutual embrace to occur between those of different backgrounds, experiences, and identities, God’s grace must work in the relationship and people most harmed by unequal structures must be empowered.62 Because often social institutions have denied the God-given dignity of people HIV/AIDS affects, the church must consciously foster hope, support, and love among these individuals. For example, several Zambian churches have begun “Circles of Hope,” which seek to embrace those affected by HIV/AIDS. The circles exhibit the presence and power of God, while also seeking to meet their members’ physical needs.63 Through the circles, HIV-positive congregants can gain the support to engage in meaningful relationships with HIV-negative people in the church and community.

The third Christian concept is humility. Humility makes it possible for those with power to exhibit a type of “double vision,” through which they first develop an equal relationship with marginalized individuals and second, they recognize that, as the powerful, their own worldviews are shaped within particular cultures and identities.64 Double vision necessitates patience, the need for displacement from the status quo, and a desire “to be influenced even when this requires giving up control.”65 Christian service emerges from this displacement, and pushes us to work toward God’s Kingdom in all areas of life. In politics, this means Christians must have broader political goals than their own narrow interests. Otherwise, Christians are no different from any other political faction.66 Their constant awareness about sin’s pervasiveness requires that Christians question their motives for demanding particular policies. Christians must utilize double vision and ask if their preferences reflect God’s call or their own cultural biases. In the context of the pandemic, Christians must humbly seek to understand the people that HIV/AIDS affects and the ways that power inequalities and socioeconomic structures shape HIV vulnerability and AIDS policies. Humility curtails the tendency toward becoming judgmental. Like the disciples who wanted to know what sins had left the blind man without sight, sometimes Christians have focused more on the behavior that led to HIV infection than on showing compassion.67 This viewpoint also hinders the “self-probing inquiry” needed “to address [the] local and socioeconomic inequalities” that affect AIDS.68

Finally, Christians must move beyond viewing HIV/AIDS as an issue demanding short-term charity to one crying out for long-term justice. In the most basic sense, justice means giving each “what was due him.”69 But Biblical justice is more than legalistic formulas; instead it “must be defined within the context of a given social order.”70 Justice is rooted in the fact that all people are image bearers and loved redemptively by God, and it entails rendering people the treatment that their inherent worth requires.71 Justice and charity differ. While charity can be the first step in fostering justice, it is insufficient by itself. Charity has the connotation of people with resources “doing for” the marginalized, instead of “doing with” them. This unequal relationship challenges the aforementioned concept of mutual embrace, and it has limited ability to foster community.72 Charity can become dangerous if those who provide it see people in need as intrinsically inferior, instead of as victims of unequal and violent socioeconomic, political, and historic processes and structures.73 This perspective disregards the Creation story, which emphasizes that God made all human beings in his image and none are superior to others.74 The charity lens also does not force us to humbly examine our participation in sinful structures such as an unjust global trading system which benefits the West.75

Power and AIDS

Political scientists and theologians have viewed the concept of power in avariety of ways. Power has been defined as participation in decision making, control over material resources and ideology, or the ability to shape the “field of action.”76 For traditionally disenfranchised individuals, such as women and the poor, the autonomy to decide on things needed to sustain a dignified life is a crucial type of power.77 We can analyze power at different levels: in relationships (power dynamics between two people or small groups); in society (power dynamics between groups or between groups and the state); and in the international realm (power relationships between states or states and non-state actors).78 Power may reside not just in the public realm of formal political institutions, but also in the private arenas of families, community organizations, and the workplace.79 Some political scientists have investigated the use of power to promote individual, group, or national interests, while others have examined how power can protect marginalized groups or poor nations.80

Some Christians have juxtaposed political power and Christian love, contrasting the “worldly” means of attaining power (social, economic, and political processes) with spiritual values of servanthood and self-denial.81 This view assumes that power fully corrupts power holders, who use it ultimately to benefit their own interests, not the common good.82 This view also may resort to seeing the “law of love as a simple solution for every communal problem.”83 In contrast, the Reformed tradition tends to stress that in a sinful world power sometimes can be used positively to foster justice. Instead of limiting power to the state, which uses it somewhat reactively to promote stability,84 the Reformed perspective asserts that seeking justice requires weighing conflicting claims, a process necessitating discernment and Christian love and one situated often in formal and informal political institutions.85

The following analysis of the intersections of power and AIDS is rooted in the above insights. I understand power to be “the ability to affect the outcomes you want and, if necessary, to change the behavior of others to make this happen.”86 Individuals may use power to control others’ resources and decisions, but they also can use power to make autonomous decisions about their own situations. Individuals and institutions possess tools of power such as rhetoric, expertise, influence, personality, networks, cultural mores, moral claims, and material resources. I assert that power may be situated in individuals, communities, states, or non-state actors such as corporations or nongovernmental organizations (NGOs). While I understand that power can be utilized to achieve particular interests or the common good, I recognize also that unequal power relations can lead to outcomes that benefit some over others. Unlike some Christians who shun power politics, I maintain that Christians must understand the dynamics of power better in particular situations. In that light, this section examines four ways that power influences the pandemic. I focus the analysis on power inequalities, and how they shape individual and group vulnerability to HIV and policy responses to the disease.

First, power shapes the environments that make some individuals more vulnerable to HIV infection than others. While some policy makers and FBOs have been quick to develop programs that address behaviors such as premarital sex or multiple sexual partners, they have done less to recognize how the environments of poverty, inequality, and powerlessness may push people to engage in these risky behaviors.87 Even when they have recognized how structures increase risk, actually implementing policies at the local level to address these structural inequalities is challenging. Such environments often affect African women, whose low levels of education and limited access to economic opportunities make them more reliant on husbands or boyfriends for financial support. Women may engage in risky sexual activities, such as sex with multiple partners or promiscuous husbands, because they need money to survive. One woman in Swaziland explained: “Women are having sex because they are hungry. If you give them food, they would not need to have sex to eat.”88 In return for money for school fees, uniforms, and books, some South African girls engage in sexual relations with wealthy older men, many of whom have had previous sexual partners. Because they wish to empower themselves through education, these girls feel powerless to resist such risky sexual advances. As a result, in several African countries, HIV infection rates among young women are higher than among their male peers. In Tanzania, for example, 6 percent of women between 20 and 24 years old are HIV positive, while 4.2 percent of men in the same age group are. Among 25 to 29 year-olds, the rates are 9.4 percent for women and 6.8 percent for men.89 The epidemic of gender-based violence also is a factor shaping women’s vulnerability. South African theologian Beverley Haddad reports that one rape occurs every 17 seconds in South Africa, and 44 percent of men in Cape Town admit to abusing their female partners.90 The church itself has not been immune, but rather “a place where sexual abuse has been allowed to take place, without legal repercussions for the mainly male perpetrators.”91

Power inequalities in society shape cultural expectations about gender. Patriarchal norms increase women’s vulnerability to HIV and decrease their power to make decisions about their relationships. Research in Zambia has shown that married women in some regions have higher HIV rates than young girls and widows, since married women are expected to have sex even if their husbands have been unfaithful.92 Wife inheritance (the practice in some African ethnic groups wherein a man becomes the husband to his brother’s wife if the brother dies) increases the risk of HIV infection as well, particularly in East Africa. In Nigeria, economic inequality and male aspirations for modern lifestyles contribute to a husband’s infidelity, a fact that increases married women’s risk of HIV infection.93 There is a strong correlation between discriminatory beliefs against women in Botswana and Swaziland and engagement in risky sexual relations outside of a monogamous relationship.94

Patriarchy and the unequal position of women in society also mean that the presence of HIV/AIDS in a household affects women and female children disproportionately. Family income is used for medicines and food for sick male bread-winners, while often girls and women are denied adequate food, educational opportunities, and health care. Women and girls do much of the work to care for the ill: cleaning and changing soiled bedding after excessive vomiting and diarrhea; doing additional farm labor; engaging in petty trade to earn money; and spending extra hours caring for children, particularly orphans.95

Often, African political institutions do not protect the rights of women. In many countries, prosecution of rapists and support for rape victims is limited. Societal attitudes about male power discourage women from reporting rape and prevent them from leaving violent partners. This culture of impunity exacerbates women’s vulnerability to HIV infection, since forced sexual relations increase the risk that HIV will be transmitted.96 Additionally, laws and political institutions often make it difficult for women to acquire the economic resources needed to leave environments with a high risk of HIV transmission. Even if countries have laws to protect women’s property rights, patriarchal attitudes and local customs may actually determine who controls a family’s resources. For example, Swaziland’s 2003 Constitution gives women equal economic and political rights with men, but because the Constitution has yet to be implemented fully, marital power has limited a woman’s ability to open a bank account or own property without her husband’s permission. One HIV-positive Swazi woman commented: “The husband is the one that bosses you around so there is nothing you can do without him. My rights lie with my husband.”97 Without power over resources, women must remain in relationships that may increase their HIV risk.

Several African theologians have called on the church to address such gender inequalities. Beverley Haddad writes: “Patriarchy in the church has provided its almost exclusively male leadership with a measure of power that enables abuse, or at least collusion in abuse of women, to continue unabated.”98 Female congregants recount stories of church leaders who admonish them with Bible verses to “be faithful” to abusive or unfaithful husbands.99 Rather than defining women as derivative, and secondary, to men, the Circle of Concerned African Women Theologians asserts that women and men are in a community of equals. As such, the church must preach that God does not intend women to be mere tools for male sexual pleasure and procreation.100 Putting such a theology into place is difficult, because often women hold few leadership positions in the church, and they are discouraged from expressing dissenting opinions. They are often asked to give inordinately of their time and money to church projects. These constraints make it “far easier for women to organise outside of church structures” than within the church.101

Children’s powerlessness over HIV infection relates directly to their mother’s power over her health. Prenatal testing and the provision of ARVs during pregnancy and childbirth are essential for prevention of HIV transmission. Yet, in 2006, only about 9 percent of HIV-positive pregnant women worldwide received ARV prophylaxis. Despite efforts by PEPFAR and the Global Fund to increase these numbers, social and economic inequality hampers these prevention programs. In Lusaka, Zambia, only 30 percent of HIV-positive pregnant women who attended public-sector clinics were successfully administered nevirapine, a drug to prevent HIV transmission. The low percentage reflects limited HIV testing, women’s fear of their partner’s reaction to their HIV status, the potential negative side effects of the drugs, women’s lack of money for transportation to clinics, and media portrayals of nevirapine’s dangers. One woman in Côte d’Ivoire explained: “My husband might see me with the medicines, and he will want to know what they are for. That way he will find out about my [HIV positive test] result.”102 If they disclose their HIV status, HIV-positive pregnant women may face spousal abuse, ostracism, and divorce.103 Power inequalities hinder women’s ability to protect their children from HIV.

Some migrants and refugees also may feel powerless, since they experience social isolation and low self-efficacy. People are more likely to engage in risky sexual relations if they do not live in supportive social environments and if they have low self-efficacy. Many migrants feel they have no choice but to take dangerous jobs far from their families, given the high rates of unemployment throughout Africa. Migrants report that trade unions and political officials do not represent their interests, and they feel powerless over their lives. One migrant to a South African mine explained: “Most of my life that I have spent here [in the migrant work camp] has not been so fruitful, and when I look ahead, I don’t see myself having a long life.”104 Migrants describe extreme loneliness as they miss their wives (if they are married) or their parents (if they are unmarried). Another South African miner said: “There is no one who can help me here.”105 The migrants’ inability to find jobs near their families contributes to the emotional isolation that may drive them to practice un-safe sexual behavior. The Christian message of caring for the marginalized, sick, and lonely challenges the church to reach out to migrants and refugees, though service delivery to them is difficult because they are often unpopular with local populations.

Second, power enables some individuals to ignore issues that affect others. Peter Bachrach and Morton Baratz describe the explicit power to make decisions and the implicit power to “effectively prevent certain grievances from developing into full-fledged issues which call for decisions.”106 This hidden face of power was evident when national and international leaders denied the seriousness of AIDS, partly because the disease is linked to intimate relations and often affects marginalized populations. Similarly, AIDS programs often have emphasized prevention (and more recently, treatment), but downplayed the need for care and support of those affected by HIV/AIDS. Because care and support programs require large amounts of money and long-term commitment, they have been underfunded or left off the policy agenda.107 Even with recent attention to AIDS, some at-risk populations such as children, youth, and intravenous drug users have received less attention than others.108 Ugandan physician and theologian Peter Okaalet writes, “Unfortunately, children are still the ‘invisible face’ of a very visible disease and are still missing out.”109 In 2006, only 10 percent of households supporting AIDS orphans received help from the public or private sectors. Similarly, programs to combat the factors that make young people (aged 15 to 24) vulnerable to HIV infection, such as early sexual debut and media images that downplay sexual risks, have received limited attention. While all AIDS programs need more commitment, the UN Secretary General and UNAIDS have specifically highlighted the woefully inadequate attention to children and youth.110 There are long-term costs for these policy choices: AIDS orphans are less likely to attend school and to get needed medical care, and they are more likely to be depressed and involved in destructive behavior.111 Without more attention to youth, infection rates in this age group continue to increase in many countries.112

As of late 2006, only 15 percent of the almost 800,000 children (individuals below 15 years old) in low- and middle-income countries who needed ARV treatment received it, half the percentage of adults. While there are logistical hurdles to pediatric treatment, such as costly ARVs and difficulty diagnosing children’s HIV infection, one of the biggest obstacles has been doubt among donors that pediatric treatment was feasible in poor countries. This prevalent attitude meant that pharmaceutical companies faced little pressure to develop cheap and easy-to-administer pediatric ARVs. More broadly, the language of feasibility and sustainability pushed the issue of children’s ARV treatment off the policy-making agenda.113 Children’s lack of political voice and inability to mobilize for political action—their relative powerlessness—made it easy to ignore them in the AIDS fight.

According to Botswanan theologian Musa Dube, because HIV/AIDS has had such a large impact on children, the church needs to develop a rights-based theology toward them. Dube outlines three biblical insights. First, Jesus presents children as the model of faith, and asserts “whoever welcomes one of these little children in my name welcomes me.”114 Children must be welcomed into the full community of faith, but they also must be welcomed into AIDS education, care, support, and treatment programs, for doing so is welcoming Christ. Second, Jesus opens the kingdom of God to children, the most marginalized members of society. Christ recognizes that children have God-given rights to be equal members of the community of faith; this equality in status means they cannot be sidelined in AIDS efforts.115 Peter Okaalet echoes this point when he argues that successful programs for orphans and vulnerable children must incorporate children’s voices and ideas into decisions that affect them.116 Third, Dube points out that Jesus gives his pronouncements about children to his male disciplines who were arguing about who is the greatest. The men (or more broadly, those with power) are charged to welcome and care for children, society’s weakest members. The implication is that without the powerful, children’s concerns in the AIDS fight will not receive attention.117

A third point about power is that it has been used to frame AIDS in ways that reflect Western interests. This trend is exemplified through the “securitization” of AIDS, or the process by which national and international officials have presented AIDS not just as a health or development issue, but also as a matter of global security. Said UNAIDS director Peter Piot, “The global AIDS epidemic is one of the central security issues for the twenty-first century.”118 The turning point in this conceptualization came in 2000, when the UN Security Council designated AIDS as a threat to peace and security. Coupled with the September 11 terrorist attacks, this action urged scholars and policy makers to hypothesize that because AIDS will decrease economic development and increase competition for scarce resources in poor countries, it will contribute to failed states, AIDS orphans mobilized into terrorist networks, and global instability.119 Though they have limited empirical support, these assertions resonate in the post-Cold War era, when threats to the West are perceived to come not from rival states, but from non-state actors.

Positively, the security framework has facilitated growth in AIDS funding and led to the development of new AIDS programs such as PEPFAR. In fact, the White House acknowledged after PEPFAR’s passage that attention to AIDS has increased with the war on terror.120 Securitizing AIDS also has contributed to greater spending on HIV prevention and ARV treatment in African militaries. Such programs are crucial for mitigating the spread of HIV, since armed forces tend to have higher-than-average HIV rates and soldiers are more likely than non-soldiers to have multiple sexual partners. On the other hand, the security focus redirects resources away from children, poor women, drug users, youth, and migrants with less political power and perceived strategic value. Scholars, AIDS activists, and public health officials have challenged the securitization of AIDS because it explicitly enables powerful actors in the West to define issues in light of their own self-interest.121 In doing so, it hampers the formation of strong, long-term partnerships between Western donors and African institutions, since each side views AIDS through a different lens. The security framework does not seek to change the underlying conditions of poverty, unequal access to health care, and global economic inequality that make some people vulnerable to HIV infection.

A final point about AIDS and power relates to representation, or whose voice is heard in decision making and to whom decision makers are accountable. Through principles it adopted in 1994, the United Nations recommends that people affected by HIV/AIDS should participate in AIDS decision-making bodies and they should be included in all AIDS forums with credibility equal to other participants. These principles are rooted in the belief that only HIV-positive people and those AIDS directly affects can understand fully the pandemic’s economic, social, and emotional impacts.122

Such inclusion can challenge the status quo, since it necessitates discussion with marginalized individuals such as women, children, youth, the poor, the addicted, and sex workers. These conversations turn power on its head, just as Christ’s dealings with some of society’s most marginalized members did. They also resonate with Christ’s call for a new kind of community, in which God’s power and presence are evident in the practice of love toward the other, no matter gender, age, wealth, or HIV status.123 For the church, inclusion means the development of a new theology that challenges tradition and forces ways of living that are redemptive for all people.124 The Reverend Cannon Gideon Byamugisha, the first African Anglican priest to declare his HIV-positive status, explains why people affected by HIV/AIDS must be included as the church develops this new theology:

This is where members of the community of the people of God, created in the image of God, are involved in a vocationally based critical and constructive interpretation of their present reality of living positively with the HIV-virus. If they are excluded, the richness of God’s love and grace is denied not only to them, but also to the rest of the apostolic faith community, which as a result of their loss will be unrepresentative, fragmented, less whole and diminished.125

Exclusion is apparent in national and international AIDS policy making. In his scathing poem “The Fat Cats,” Zimbabwean actor, poet, and AIDS activist Elliot Magunje, who died of AIDS in 2003, argues that international AIDS experts benefit from exclusive policy-making structures while people with AIDS are voiceless subjects of discussion. While Magunje’s angry assertion that donors and experts have “done more harm than good” is extreme, his points about unequal representation should not be discounted:

Your talking for me has been unfair.
Your talking for my colleagues is suspect.
In your arrogance you call me destitute.
In your executing posture you call me victim. . . .
No more passing policies for me without me.
No more talking for me without me.126

One reason for this low representation in policy making is that many AIDS associations lack material resources and political connections. AIDS kills group members and leaders, making it difficult to sustain political action.127 African governments and international donors also have made uneven efforts to include people affected by the disease in decision making. For example, the Global Fund requires that an applicant nation form a country-coordinating mechanism composed of representatives from the state, civil society associations, business groups, academic institutions, FBOs, and international donor organizations. This decision-making board designs a plan for the country’s AIDS, TB, and/or malaria efforts, writes a grant proposal to the Global Fund, and administers any money the country receives. The Global Fund strongly urges countries to place officials from AIDS, TB, and malaria associations on these boards, but there are no required quotas for representation. In 2005, most country-coordinating mechanisms had one representative from one disease-affected population, but this person’s voice was often limited because of the large size of the board.128 Governments appointed many of these representatives, who were unwilling to challenge AIDS policies and felt limited accountability to their group members.129

Another obstacle to effective representation is AIDS-related stigma. UN AIDS defines stigma as “a process of ‘devaluation’ of people either living with or associated with HIV and AIDS.”130 Often the person with HIV/AIDS is viewed explicitly or implicitly to be worthless because the spread of HIV is linked to socially unacceptable actions such as promiscuity, prostitution, drug use, and sexual abuse. Stigma prevents those affected by HIV/AIDS from mobilizing for political action and it can cause policy makers to pay less attention to them. Because stigma may lead people HIV/AIDS affects to lose property, jobs, and status in the community, it limits their economic resources and political power even further.131 Stigma denies the God-given dignity of those affected by HIV/AIDS and their place in Christ’s community. A refrain African pastors and AIDS workers hear often is, “I died whenI was diagnosed,” a statement that demonstrates how AIDS and AIDS-related stigma deny physical, social, and spiritual life.132

In summary, power inequalities shape the pandemic. People with few material resources, little community support, and minimal social status often live in contexts in which power over their situations is limited. These factors make women, children, young people, migrants, and refugees vulnerable to HIV. Power also shapes responses to the pandemic, since church leaders, political officials, and international donors can frame policy approaches and they can include or exclude the voices of those most affected by HIV/AIDS.

Christians and the Politics of AIDS

Given these unequal power dynamics, how do the above-outlined Christian principles shape Christians’ role in the politics of AIDS? First, since humans are created in God’s image, Christians must value the unique gifts and stories of people affected by AIDS. Christians must resist attempts to portray Africans with AIDS as “the distant other.” The involvement of Western celebrities in calling attention to HIV/AIDS could be examined in this light. Positively, individuals such as Bono,Scarlett Johansson, and Oprah Winfrey have brought a human face to AIDS and the continent. This is important, since many in the West pay little (if any) attention to Africa. Similarly, Product (RED)TM has the potential to raise a considerable amount of money from Western consumers. On the other hand, we Christians must practice mature discernment about such celebrity involvement. For some consumers, part of the attraction of Product (RED)TM has been its link to healthy and beautiful people, whose glamorous images contrast with the pictures of the thin HIV-positive mother or the young man dying from AIDS.133 The subliminal juxtaposition of celebrities and people with AIDS may enable Western consumers to distance themselves from Africans and to forget the interdependence of all God’s people. This distancing may allow Christians in industrialized countries to practice charity but ignore justice, if they forget how power relations affect the pandemic.

To combat such possibilities, Christian activists and FBOs must use their power to advocate for the inclusion of HIV-positive people in decision-making positions, and FBOs must incorporate their perspectives into AIDS program designs. In th epast few years, this trend has become more apparent. For example, churches and FBOs have formed coalitions with organizations of people who are HIV-positive to advocate for specific AIDS policies. Churches have developed support organizations in their own congregations and churches/FBOs have hired people who are HIV-positive to become AIDS educators. Religious leaders also have become more open about the disease, forming the African Network of Religious Leaders Living with or Personally Affected by HIV/AIDS.134

Recognizing that all individuals are made in God’s image necessitates that Christians counter society’s attempts to dehumanize people with AIDS through AIDS-related stigma. Challenging stigma emulates the gift of God’s embrace of this sinful world. Through his interactions with the ostracized and powerless, Christ acknowledged the dignity of excluded people and facilitated their restoration into the community.135 While many secular and faith-based organizations have not challenged stigma directly, some positive examples exist. The Council of Churches in Zambia proclaimed, “Since some members of the church are positively infected, we can safely say that the Church, the body of Christ, has AIDS.”136 Church leaders refer increasingly to “those of us with AIDS,” to illustrate that the HIV-positive churchgoer is not distinct from other believers.137 The Anglican Church of Mozambique states, “In Christ there is no positive or negative.”138 Similarly, the secular Treatment Action Campaign (TAC) in South Africa has promoted the self-efficacy of its members, the majority of whom are HIV-positive and women. TAC has taught its members about AIDS and treatment options, trained them for leadership positions, and given them authentic decision-making power in the organization. It has stressed that people with HIV/AIDS can live positively and can contribute greatly to society. This empowerment has enabled TAC to successfully challenge the South African government to provide access to ARV treatment for all HIV-positive people who need it.139

As people called to live in community, Christians must exhibit a long-term commitment to AIDS and the people the disease affects.140 With the recognition that power enables policy makers, particularly in the West, to ignore or reframe issues, Christians must demand that donor governments do not push AIDS from the policy-making agenda or ignore their funding promises. For example, Christians can lobby the U.S Congress to appropriate the almost $50 billion it approved when it reauthorized PEPFAR for another five years in mid-2008. Additionally, Western Christians can urge denominations to give more money to support African churches and FBOs grappling with AIDS. For example, while many African seminaries have incorporated HIV/AIDS education into their curriculum, these schools need resources and spiritual support to educate on the difficult issues of gender-based violence, child abuse, poverty, and sexuality.141

An emphasis on community leads Christians to care about the needs of others, not just their own interests. While Western Christians should be concerned about national security, they must be savvy about the potential drawbacks of the securitization of AIDS. The security framework may cause donors to give AIDS money to countries of strategic value to the West regardless of their disease burden.142 (For example, as of mid-2007, Uganda, a U.S. ally in the war on terror, had received three times the amount per HIV-positive person from PEPFAR as Tanzania had.) The security framework may work against grassroots efforts to fight the AIDS stigma, if it dehumanizes people with AIDS and paints them as “threats.” In contrast, people with cancers, respiratory infections, cardiovascular diseases, and malaria—all health conditions that kill millions annually—are not portrayed in threatening ways.143 Framing AIDS as a security concern also may cause global AIDS efforts to diminish if AIDS is no longer perceived to threaten Western interests.

Humility requires Western Christians to resist the belief that their AIDS policies are always correct. Even though the West provides much money for AIDS, Western Christians must not exhibit what Bryant Myers terms “God complexes” in program priorities and design. Instead, we must remember Christ’s admonition to not ignore the planks in our own eyes as we point out the specks in our neighbors’.144 Humility means recognizing how power inequalities make some groups more vulnerable to HIV infection. It also requires seeking actively to hear the ideas of Africans who struggle daily with the disease and its impact. A long-term partnership between the poor and non-poor is only feasible with this equal relationship.145 Humility may cause FBOs and Christian activists to redefine their roles in AIDS advocacy and program delivery. For example, when we acknowledge that individual sexual behavior is situated within larger socioeconomic and cultural contexts, we then can advocate for long-term development programs that will address the poverty, gender inequality, and economic stagnation that create HIV risk environments. Humility also means acknowledging that Africans have provided countless hours and immeasurable energy to home-based care, HIV education, and advocacy. Africans, not Westerners, are the biggest players in the AIDS fight.

Fostering justice on HIV/AIDS means that Western Christians use power positively. The church’s tools of persuasion, resource mobilization, moral authority, and political connections facilitate advocacy to change the economic, social, and cultural structures that make AIDS so destructive in Africa. U.S. Christians must lobby not only for AIDS-specific programs such as PEPFAR, but also for trade agreements that give African farmers an equal chance in Western markets or for more money for clean water sources for the 314 million Africans without them.146 Such advocacy also could include holding the Group of Eight industrialized nations accountable for their 2005 promises of $50 billion for Africa’s economic development and $40 billion for debt relief.147 In Africa, churches must also use their power of moral persuasion to push their governments to create more just societies, which provide jobs, facilitate gender equality, and promote health and education.148 The Ecumenical Advocacy Alliance, composed of 90 Christian organizations world-wide, outlines this justice perspective in its 2005 framework for AIDS action:

Churches must continue to speak out against the causes and effects of poverty, and make HIV and AIDS visible as a poverty-related disease…. The spread and impact of the pandemic mean that HIV and AIDS cannot be addressed solely as a health ministry within the church.149

A justice-focused approach to AIDS urges FBOs to couple prevention messages about abstinence, monogamy, and condoms with development projects that increase incomes, empower women, and combat social isolation. Most AIDS efforts are narrowly focused: they specialize in ARV treatment, care and support for those with AIDS, or HIV prevention. Not only must treatment, care/support, and prevention programs be better integrated, but all of these efforts must address the power inequalities that hinder people from using knowledge to prevent HIV infection or from accessing treatment and care programs.150 Positively, a few FBOs have started to realize that development initiatives and AIDS efforts must be integrated better. In Zambia, World Vision International has worked with business organizations, local churches, and other multinational FBOs and NGOs to promote food security in areas with high HIV prevalence rates. Food security not only ensures better health and nutrition for AIDS orphans and people infected with HIV, but it also prevents marginalized people (such as women) from turning to risky sexual relations to gain food for themselves and their children.151 By working for social justice, organizations can approach problems innovatively from a variety of angles. For example, the belief that all people have a right to health care pushed the organization Partners in Health to devise new ways of service delivery for TB and AIDS patients.152

Finally, Christian educators are crucial players in a justice-focused approach to HIV/AIDS. Just as African seminaries incorporate HIV/AIDS into coursework, Western seminaries that train pastors for work in a global church must pay greater attention to AIDS, poverty, gender vulnerabilities, and global inequalities.153 For those of us who teach about global development, international health, and world politics, we must educate our students about the complexities of the pandemic, since a church committed to AIDS needs “sharp minds and intellectual sophistication.”154 However, instead of letting the complexity of AIDS overwhelm and paralyze our students, we must stress that God empowers his people to act in their churches, occupations, the voting booth, and the classroom. Nehemiah 2 teaches us that leadership requires studying a problem, praying for guidance, listening to those affected, and developing a plan of action. In my special topics course on AIDS in Africa, students complete projects that translate their knowledge of AIDS into action. In the past, these have included writing Bible study guides on HIV/AIDS, designing media presentations to educate congregations, developing criteria to assess the AIDS and poverty reduction policies of political candidates, and designing personal plans for academic study in poor countries.

Tinyiko Maluleke writes that the AIDS pandemic provides the church with “both a moment of truth in critical and dangerous times and a moment of grace and opportunity.”155 Christians have much to bring to the AIDS fight. Our belief that God gives all people dignity urges us to see the millions of people HIV/AIDS affects as individuals whom God loves. We mourn the fact that AIDS has tainted God’s creation, but our faith in a risen Christ brings hope when the pandemic seems overwhelming. Such hope pushes our activism and energizes us when it seems that government programs, faith-based efforts, and international funding have little impact on the spread of HIV/AIDS. Yet, as we dream of a world without the pandemic, our day-to-day efforts must be rooted in an appreciation of the complex power dynamics embedded in AIDS.156

Cite this article
Amy Patterson, “A Question of Power: A Political Scientist Responds to AIDS in Africa”, Christian Scholar’s Review, 38:2 , 231-257


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  2. UNAIDS, 2007 UNAIDS/WHO AIDS EpidemicUpdate, (accessed December 15, 2007), 6-7.

  3. In recent years, some AIDS activists and scholars have begun to use “HIV & AIDS” insteadof “HIV/AIDS” to distinguish the virus from the diseases that accompany AIDS. Becausemuch of the AIDS literature still uses HIV/AIDS, I will do the same. When I refer to “peopleaffected by HIV/AIDS,” this includes HIV-positive individuals and their HIV-negative fam-ily and friends who experience the disease’s physical, emotional, economic, and social rami-fications.
  4. Elias K. Bongmba, Facing a Pandemic: The African Church and the Crisis of AIDS (Waco, TX:Baylor University Press, 2007), 23; and Peter Okaalet, “The Role of Faith Based Organiza-tions in the Fight against HIV and AIDS in Africa,” Transformation 19.4 (2002): 275.
  5. Jeffrey L. Sheler, “Prescription for Hope,” U.S. News & World Report, Web Exclusive, Febru-ary, 12, 2002, (ac-cessed January 14, 2008).
  6. Greg Behrman, Invisible People: How the U.S. Has Slept through the Global AIDS Pandemic(New York: Free Press, 2004), 273, 286.
  7. ames Guth, John Green, Lyman Kellstedt, and Corwin Smidt, “Faith and Foreign Policy: AView from the Pews,” The Review of Faith & International Affairs 3.2 (2005): 7.
  8. Amy Patterson, The Politics of AIDS in Africa (Boulder, CO: Lynne Rienner, 2006), 138-139;and Michael Fletcher, “Bush to Seek Extension of AIDS Effort,” Washington Post, May 30,2007, A1.
  9. Guth, Green, Kellstedt, and Smidt, “Faith and Foreign Policy,” 9.

  10. Kaiser Family Foundation, “The Public’s Knowledge and Perceptions about HIV/AIDS,”Public Opinion Spotlight, August 2006, (accessed January 14, 2008), 1, 3. Common misconceptions about HIV transmission are thatHIV can be transmitted through kissing and through sharing a drinking glass.

  11. I use pandemic to refer to the spread of HIV/AIDS across Africa. An epidemic occurs whenthe incidence of a disease exceeds the expected rate in a particular country. A pandemic is anepidemic that exists across multiple countries.
  12. Emmanuel Katongole, A Future for Africa: Critical Essays in Christian Social Imagination(Scranton, PA: University of Scranton Press, 2005), 30. For an analysis of media images, see“Representing HIV/AIDS in Africa: Pluralist Photography and Local Empowerment,” Inter-national Studies Quarterly 51.1 (2007): 139-163. For examples of church materials, see the “It’sa Matter of Faith” campaign from Presbyterian Church (USA) and the “Embrace AIDS” cam-paign from Christian Reformed World Relief Committee. Church World Service and WorldVision International have similar materials on their websites. See;;; and (allaccessed May 31, 2007).
  13. 3UNAIDS, 2007 UNAIDS/WHO AIDS EpidemicUpdate, 15-20. In its 2007 report, UNAIDSrevised some of its HIV prevalence estimates, as a result of better data collection methods and increased data availability.
  14. Because homosexual acts are illegal in most African countries, it is impossible to know thenumber of HIV transmissions that occur through men who have sex with men. Likewise,estimates of the number of transmissions through intravenous drug use are unreliable.
  15. UNAIDS, 2007 UNAIDS/WHO AIDS EpidemicUpdate, 8.
  16. Quarraisha Abdool Karim, “Address” (speech at the Global AIDS Conference, Bangkok,July 17, 2004).
  17. 7Sheri Weiser, Karen Leiter, David Bangsberg, Lisa Butler, Fiona Percy-de Korte, ZakheHlanze, Nthabiseng Phaladze, Vincent Iacopino, and Michele Heiser, “Food Insufficiency isAssociated with High-Risk Behavior among Women in Botswana and Swaziland,” PLoSMedicine 4.10 (2007): 1590-1591.
  18. UNAIDS, 2007 UNAIDS/WHO AIDS EpidemicUpdate, 7.
  19. World Health Organization, “Taking Stock: HIV in Children,” 2007 Fact Sheet, (accessed June 2, 2007), 2. ARVshave made AIDS a manageable health condition for many people in the West and they haveprevented thousands of children from being born HIV-positive.
  20. UNAIDS, 2007 UNAIDS/WHO AIDS Epidemic Update, 8.
  21. Ibid., 12-14; and UNAIDS, “Young People,” 2007 Fact Sheet, (accessed January 14, 2008), 1.
  22. ony Barnett and Alan Whiteside, AIDS in the Twenty-First Century: Disease and Globaliza-tion (New York: Palgrave Press, 2002), 117-123.
  23. UN Educational, Scientific and Cultural Organization and UN High Commissioner forRefugees, “Educational Responses to HIV and AIDS for Refugees and Internally DisplacedPersons: Discussion Paper for Decision-Makers,” 2007 Report, (accessed January 14, 2008), 8-9. Though there is limitedresearch on the topic, conflict also may prevent HIV transmission by reducing mobility fromurban to rural areas and by isolating some at-risk populations.
  24. 4Patterson, Politics of AIDS, 7.25.
  25. Barnett and Whiteside, AIDS in the Twenty-First Century, 185-189
  26. Human Rights Watch, “Policy Paralysis: A Call for Action on HIV/AIDS-Related HumanRights Abuses against Women and Girls in Africa,” 2003 Report, (accessed July 1, 2004), 17.
  27. 7Gabriel Rugalema, “Coping or Struggling? A Journey into the Impact of HIV/AIDS inSouthern Africa,” Review of African Political Economy 26.86 (2002): 538.
  28. Carolyn Baylies, “The Impact of AIDS on Rural Households in Africa: A Shock Like AnyOther?” Development and Change 33.4 (2002): 614. See also Barnett and Whiteside, AIDS in theTwenty-First Century, 182. As one reviewer pointed out, even the gain for coffin makers isshort term, since in countries with high HIV prevalence rates, these individuals are likely tobe affected by HIV/AIDS at some future point.
  29. Patterson, Politics of AIDS, 2.
  30. 0Randy Cheek, “Playing God with HIV: Rationing HIV Treatment in Southern Africa,” Afri-can Security Review 10.4 (2001): 19-28.
  31. Donald Messer, Breaking the Conspiracy of Silence: Christian Churches and the Global AIDSCrisis (Minneapolis, MN: Fortress Press, 2004), 6.
  32. Behrman, Invisible People, 218-235.

  33. UN Secretary General, Declaration of Commitment on HIV/AIDS: Five Years Later, 2006 Reportto the General Assembly, (accessed April 10, 2006), 6.
  34. Okaalet, “The Role of Faith Based Organizations,” 276.
  35. Behrman, Invisible People, 233. Some public health officials have criticized the move awayfrom these early approaches that integrated HIV prevention into family planning programs.See Craig Timberg, “‘Best-Kept Secret’ for HIV-Free Africa,” Washington Post, December 16,2007, A26.
  36. UNAIDS, “Financial Resources Required to Achieve Universal Access to HIV Prevention,Treatment, Care and Support,” 2007 Report, (accessed January 10, 2008), 4.
  37. Updated statistics on the progress of the Global Fund and PEPFAR are available at and (both accessed June 12, 2007).
  38. Information on the Gates Foundation’s programs in global health is available at (accessed January 14, 2008).
  39. According to the website for Product (RED)TM, the parentheses used in the logo are calledan “embrace.” Each company with a product places its logo in the embrace and is “thenelevated to the power of red.” See (accessed June 4, 2007).
  40. 0See aforementioned websites for the Global Fund and PEPFAR.
  41. Lisa Ann Richey and Stefano Ponte, “Better (RED)TM Than Dead: ‘Brand Aid,’ Celebritiesand the New Frontier of Development Assistance” (working paper no. 2006/26, Danish In-stitute for International Studies, Copenhagen, 2006), 22.
  42. Bongmba, Facing a Pandemic, 45; and Paul Farmer, Pathologies of Power: Health, Human Rights,and the New War on the Poor (Berkeley, CA: University of California Press, 2005), 152.
  43. Japhet Ndhlovu, “Combating HIV: A Ministerial Strategy for Zambian Churches” (PhDdiss, University of Stellenbosch, Stellenbosch, South Africa, n.d.), 96-98.
  44. Bongmba, Facing a Pandemic, 50.
  45. Martin Heidegger, Being and Time (Norwich, UK: SCM Press, 1962), 20.
  46. Katherine Marshall, “Development and Religion: A Different Lens on Development De-bates,” Peabody Journal of Education 76.3&4, (2001): 350; and Okaalet, “The Role of Faith BasedOrganizations,” 277.
  47. Cornelius Plantinga, Engaging God’s World: A Reformed Vision of Faith, Learning, and Living(Grand Rapids, MI: Eerdmans, 2002), 33.
  48. Miraslov Volf, Exclusion and Embrace: A Theological Exploration of Identity, Otherness, andReconciliation (Nashville, TN: Abignon Press, 1996), 225. See also Philippians 2:4-5.
  49. Thomas Marshall, Class, Citizenship and Social Development (New York: Doubleday, 1964),78; and David Koyzis, Political Visions and Illusions (Downers Grove, IL: InterVarsity Press,2003), 48-50.
  50. See 1 Corinthians 11:17-22.
  51. 1Charles Marsh, The Beloved Community: How Faith Shapes Social Justice from the Civil RightsMovement to Today (New York: Basic Books, 2005), 1-2. See also 1 John 4:19-21.
  52. 2Bongmba, Facing a Pandemic, 179.
  53. Paul Henry, Serving the Claims of Justice (Grand Rapids, MI: Paul Henry Institute, CalvinCollege, 2001), 80-81; and Bongmba, Facing a Pandemic, 52, 120.
  54. Ezra Chitando, “Relevant Theological Education in the HIV and AIDS Era” (presentationto the Network of African Congregational Theology Conference, Lusaka, Zambia, August 7,2007).
  55. Examples include Jonah (Jonah 1-2), David (2 Samuel 11-24), and Jesus’ parable of thesheep and goats (Matthew 25:31-46).
  56. Katongole, A Future for Africa, 31.
  57. Ibid.
  58. Farmer, Pathologies of Power, 138; and Barbara Schmid, “AIDS Discourses in the Church:What We Say and What We Do,” Journal of Theology of Southern Africa 125 (2006): 102.
  59. 9Ronald Sider, Just Generosity (Grand Rapids, MI: Baker Books, 1999), 59.
  60. See John 8:1-11; Luke 18:35-42; Matthew 9:9-12; Luke 5:12-15; and Luke 8:43-48.
  61. Beverly Haddad, “Gender Violence and HIV/AIDS: A Deadly Silence in the Church,” Jour-nal of Theology for Southern Africa 114 (2002): 98.
  62. Volf, Exclusion and Embrace, 99.
  63. Ndhlovu, “Combating HIV,” 100, 140-141.
  64. Volf, Exclusion and Embrace, 213.
  65. 5Henri Nouwen, Donald McNeill, and Douglas Morrison, Compassion: A Reflection on theChristian Life (New York: Image Books, 1983), 93.

  66. Stephen Monsma, “Christian Commitment and Political Life,” in In God We Trust? Ed.Corwin Smidt (Grand Rapids, MI: Baker Books, 2001), 255-268.
  67. Bryant Myers, “Africa and HIV/AIDS: Who Is My Sister, My Brother?” MARC Newsletter2.4 (2002): 2. See John 9:2.
  68. 8Bongmba, Facing a Pandemic, 54.
  69. Nicholas Wolterstorff, Until Justice and Peace Embrace (Grand Rapids, MI: Eerdmans, 1983),77.

  70. Henry, Serving the Claims, 87.
  71. 71Nicholas Wolterstorff, Justice: Rights and Wrongs (Princeton, NJ: Princeton University Press,2008), 323.
  72. Volf, Exclusion and Embrace, 50, 100-112, 212.
  73. Farmer, Pathologies of Power, 153.
  74. Bongmba, Facing a Pandemic, 69.
  75. Paulo Freire, Pedagogy of the Oppressed (New York: Continuum Press, 1986), 29.
  76. Patricia Siplon, “Power and the Politics of HIV/AIDS,” in The Global Politics of AIDS, eds.Paul Harris and Patricia Siplon (Boulder: Lynne Rienner Publishers, 2007), 17-34.
  77. Martha Nussbaum, Women and Human Development: The Capabilities Approach (London: Cambridge University Press, 2000), 8-9; and Linda Barclay, “Autonomy and the Social Self,”in Relational Autonomy: Feminist Perspectives on Autonomy, Agency and the Social Self, eds.Catriona Mackenzie and Natalie Stoljar (New York: Oxford University Press, 2000), 52-71.
  78. Siplon, “Power and the Politics of HIV/AIDS,” 20.
  79. Ibid., 21.
  80. On the use of power for particular interests see Kenneth Waltz, Theory of International Poli-tics (Reading, PA: Addison Wesley, 1979), 126-127; John Mearsheimer, The Tragedy of GreatPower Politics (New York: Norton, 2001), 42-51; and Susan Sell and Aseem Prakash, “UsingIdeas Strategically: The Contest Between Business and NGO Networks in Intellectual Prop-erty Rights,” International Studies Quarterly 48.1 (2004): 143-175. On the use of power forbroader interests, see Allen Hertzke, Freeing God’s Children (New York: Rowman & Littlefield,2004), 36-39; and Joseph Nye, The Paradox of American Power (New York: Oxford UniversityPress, 2002), 162.
  81. John Howard Yoder, The Politics of Jesus (Grand Rapids: Eerdmans, 1972), 250.
  82. Jim Wallis, “Seduced by Power,” Sojourners 28.6 (1999): 16.
  83. Harry R. Davis and Robert C. Good, eds., Reinhold Niebuhr on Politics (New York: Scribner,1960), 163; and Henry, Serving the Claims, 84-88.
  84. On this Lutheran view of the state, see James Gustafson, Protestant and Roman CatholicEthics (Chicago: University of Chicago Press, 1978), 178

  85. Reinhold Niebuhr, Love and Justice, ed. D. B. Robertson (Philadelphia: Westminster, 1957),28-29.
  86. Joseph Nye, “The Limits of American Power,” Political Science Quarterly 117.4 (2002): 548.
  87. Eileen Stillwaggon, AIDS and the Ecology of Poverty (New York: Oxford University Press,2006), 13.
  88. hysicians for Human Rights, Epidemic of Inequality: Women’s Rights and HIV/AIDS inBotswana & Swaziland, 2007 Report, (accessed May 30, 2007), 102.
  89. Patricia Siplon, “AIDS and Patriarchy: Ideological Obstacles to Effective Policy Making,”in The African State and the AIDS Crisis, ed. Amy Patterson (Aldershot, UK: Ashgate Publish-ing, 2005), 17-36.
  90. Beverly Haddad, “Gender Violence and HIV/AIDS,” 94.
  91. 1Haddad, “Reflections on the Church and HIV/AIDS,” Theology Today 62 (2005): 34-35.
  92. Carolyn Baylies, “HIV/AIDS and Older Women in Zambia: Concern for Self, Worry overDaughters, Towers of Strength,” Third World Quarterly 23.2 (2002): 351-375.
  93. D. J. Smith, “Modern Marriage, Men’s Extramarital Sex, and HIV Risk in SoutheasternNigeria,” American Journal of Public Health 97.6 (2007): 997-1005.
  94. Physicians for Human Rights, Epidemic of Inequality, 6. One of these discriminatory beliefsis the idea that it is more important for women to respect their husbands than for husbandsto respect their wives.
  95. Patricia Siplon and Kristin Novotny, “Overcoming the Contradictions: Women, Autonomy,and AIDS in Tanzania,” in The Global Politics of AIDS, eds. Paul Harris and Patricia Siplon(Boulder, CO: Lynne Rienner Publishers, 2007), 87-108.
  96. Human Rights Watch, A Dose of Reality: Women’s Rights in the Fight Against HIV/AIDS, 2005 Report, (accessedAugust 15, 2006), 2.

  97. Physicians for Human Rights, Epidemic of Inequality, 108.
  98. Haddad, “Gender Violence and HIV/AIDS,” 98.
  99. Ibid.
  100. Circle of Concerned African Women Theologians, “Sex, Stigma and HIV/AIDS: AfricanWomen Challenging Religion, Culture and Social Practices,” Report of the 3rd Pan AfricanConference, Addis Ababa, Ethiopia, August 4-8, 2002, (accessed January 17, 2008).
  101. Haddad, “Gender Violence and HIV/AIDS,” 101.
  102. Avert, “Preventing Mother-to-Child Transmission,” 2007 Fact Sheet, (accessed June 13, 2007), 1.
  103. Not all women disclose their status to their partners. One study of roughly 900 pregnantwomen in Abidjan who received HIV tests revealed that within a two-year period after thetest, only 46 percent of those who tested HIV positive disclosed to their male partner. SeeHermann Brou, Gérard Djohan, Renaud Becquet, Gérard Allou, Didier Ekouevi, Ida Viho,Valériane Leroy, Annabel Desgrées-du-Lou, ANRS 1201/1202/1253 Ditrame Plus StudyGroup, “When Do HIV-Infected Women Disclose Their HIV Status to Their Male Partner andWhy? A Study in a PMTCT Programme, Abidjan,” PLoS Medicine 4.12 (2007): 1.
  104. 4Catherine Campbell, Letting Them Die: Why HIV/AIDS Prevention Programs Fail(Bloomington, IN: Indiana University Press, 2003), 30.
  105. Ibid., 33
  106. Peter Bachrach and Morton Baratz, “Decisions and Nondecisions: An Analytical Frame-work,” American Political Science Review 57.3 (1963): 641.
  107. Funding for care and support programs is only 15 percent of the PEPFAR budget. Whilean additional 10 percent goes to orphans and vulnerable children, the number of individualsover 15 years old requiring care and support continues to increase.
  108. Given space limitations, I do not discuss intravenous drug users. See Human Rights Watch,Preventing the Further Spread of HIV/AIDS: The Essential Role of Human Rights, 2006 Report, (accessed August 4, 2006).
  109. Peter Okaalet, “Some Religious Responses to HIV/AIDS and Children in Africa,” Religion& Theology 14 (2007): 95.
  110. Avert, “HIV Treatment and Children: The Issues,” 2007 Fact Sheet, (accessed January 23, 2008), 1.
  111. 1Amy Patterson, “AIDS, Orphans and the Future of Democracy in Africa,” in The Childrenof Africa Confront AIDS, eds. Arvind Singhal and Stephen Howard (Athens, OH: Ohio Uni-versity Press, 2003) , 13-39.
  112. UNAIDS, “Young People,” 1.
  113. Doctors Without Borders, “New MSF Data Shows that Treatment of Children Works inResource Poor Settings,” Press Release, August 15, 2006, (accessed June 15, 2007), 1.
  114. See Mark 9:33-37. Dube’s points could be extended to youth, though she specifically ex-amines children.
  115. Musa Dube, “Fighting with God: Children and HIV/AIDS in Botswana,” Journal of Theol-ogy for Southern Africa 114 (2002): 32-33. See Mark 10:13-16.

  116. Okaalet, “Some Religious Responses to HIV/AIDS and Children,” 101.
  117. Dube, “Fighting with God,” 41.
  118. Peter Piot, “UNAIDS Head Speaks on AIDS and Global Security” (speech, United NationsUniversity, Tokyo, October 2, 2001).
  119. For two examples of this scholarship, see Andrew Price-Smith, The Health of Nations: Infec-tious Diseases, Environmental Change, and Their Effects on National Security and Development(Cambridge: MIT Press, 2002); and Robert Ostergard, ed., HIV/AIDS and the Threat to Nationaland International Security (New York: Palgrave MacMillan, 2007).
  120. Richard Stevenson, “New Threats and Opportunities Define U.S. Interests in Africa,” NewYork Times, July 7, 2003, A1.
  121. Stefan Elbe, “Should HIV/AIDS Be Securitized? The Ethical Dilemmas of Linking HIV/AIDS and Security,” International Studies Quarterly 50 (2006): 119-144. An anonymous re-viewer echoed these criticisms.
  122. Siplon, “AIDS and Patriarchy,” 30.
  123. Ndhlovu, “Combating HIV,” 100.
  124. Chitando, “Relevant Theological Education;” Haddad, “Gender Violence and HIV/AIDS,”103; Ndhlovu, “Combating HIV,” 143; and Haddad, “Reflections on the Church,” 33.
  125. Gideon Byamugisha, Journeys of Faith: Strategies for Hope (St. Albans, UK: Teaching-aids atLow Cost, 2002), 23-24.
  126. The entire poem is available at Museum of World Cultures, (accessed June 4, 2007).
  127. Patterson, Politics of AIDS, 99-110.
  128. Patterson, Politics of AIDS, 74-75. Most representatives were from AIDS groups, a fact which raises questions about why people with TB and malaria have not mobilized.
  129. Global Network of People Living with HIV/AIDS, A Multi-Country Study of the Involve-ment of People Living with HIV/AIDS (PLWHA) in the Country Coordinating Mechanisms (CCM),2004 Report, (accessed August 1, 2005), 4-5.
  130. UNAIDS, “Reducing HIV Stigma and Discrimination: A Critical Part of National AIDSProgrammes,” 2007 Report, (accessed January 29, 2008), 9.
  131. 1Human Rights Watch, A Dose of Reality, 2.1
  132. Gerald West, “Reading the Bible in the Light of HIV/AIDS in South Africa,” EcumenicalReview 55.4 (2003): 336.
  133. Richey and Ponte, “Better (RED)TM Than Dead,” 21.
  134. Michael Kelly, “The Response of the Christian Churches to HIV and AIDS in Zambia,” inChristian Ethics and HIV/AIDS in Africa, ed. James Amanze (Gaborone: Bay Publishing, 2006),1-21; and Ndhlovu, “Combating HIV,” 77-79.
  135. Volf, Exclusion and Embrace, 146.
  136. Kelly, “The Response of the Christian Churches,” 13.
  137. Chitando, “Relevant Theological Education.”
  138. Rebecca Vander Meulen (Niassa Diocese HIV/AIDS Coordinator, Anglican Church ofMozambique) in discussion with author, June 4, 2007, Grand Rapids, MI.
  139. Steven Friedman and Shauna Mottiar, “A Moral to the Tale: The Treatment Action Cam-paign and the Politics of HIV/AIDS” (working paper for the Centre for Policy Studies, Durban,University of KwaZulu-Natal, 2004).
  140. Okaalet, “The Role of Faith-Based Organizations,” 277.
  141. Circle of Concerned African Women Theologians, “Sex, Stigma, and HIV/AIDS.”
  142. Simon Rushton, “Securitizing HIV/AIDS: Pandemics, Politics and SCR 1308” (presenta-tion at the International Studies Association Conference, Chicago, March 1, 2007).
  143. 3Elbe, “Should HIV/AIDS Be Securitized?” 137. Data on disease burden available at (accessed June 1, 2007).
  144. Bryant Myers, Walking with the Poor: Principles and Practices of Transformational Development(Maryknoll, MD: Orbis Books, 2001), 99; and Matthew 7:3.
  145. Roland Hoksbergen, “Partnering for Development: Why It’s So Important, Why It’s SoHard, How to Go About It,” REC Focus 3.4 (2003): 3-21.
  146. UN Development Program, Summary: Human Development Report, 2006 Report, (accessed January 18, 2008), 11,15. The lack of clean water and sanitation contributes to 1.8 million child deaths from diarrhea globally each year, or 4,900 each day.
  147. Celia Dugger, “Rock Star Still Hasn’t Found the African Aid He’s Looking For,” New YorkTimes, May 15, 2007, A6.
  148. Bongmba, Facing a Pandemic, 120-123.
  149. Ecumenical Advocacy Alliance, “Framework for Action: The HIV and AIDS Campaign(2005-2008),” 2005 Report, (accessed March 12, 2007).
  150. Siplon, “Power and the Politics of HIV/AIDS,” 31; Campbell, Letting Them Die, 35; andJustin Parkhurst, “The Crisis of AIDS and the Politics of Response: The Case of Uganda,”International Relations 15.6 (2001): 69-87.
  151. Information on the Zambia project is available at June 28, 2007).
  152. Farmer, Pathologies of Power, 158.
  153. Circle of Concerned African Women Theologians, “Sex, Stigma and HIV/AIDS.”
  154. Chitando, “Relevant Theological Education.”
  155. Tinyiko Maluleke, “The Challenge of HIV/AIDS for Theological Education,” Missionalia29 (2001): 130.
  156. I am grateful to Don DeGraaf, Roland Hoksbergen, Don King, Tracy Kuperus, and twoexternal reviewers for helpful comments. Two faculty reading groups (one in 2002-2003 andanother in 2006-2007) sparked my thinking for this article. Both groups were sponsored bythe Calvin Center for Christian Scholarship.

Amy Patterson

Calvin University
Ms. Patterson is Associate Professor of Political Science at Calvin College.