The Approach of Churches and Church-Related Organizations to HIV/AIDS Programmes: Based on Case Studies in Ethiopia and Southern India

Contents

List of Tables

1 Introduction

2 HIV/AIDS - Basic Facts and Problems
2.1 Basic Facts and Background on HIV/AIDS
2.2 Main Problems of the HIV/AIDS Disease
2.3 HIV/AIDS Globally - Epidemiological Data

3 Country Profiles of Ethiopia and India Regarding HIV/AIDS
3.1 Political, Demographic and Socio-Economic Characteristics of Ethiopia
3.2 HIV/AIDS in Ethiopian Context
3.3 Political, Demographic and Socio-Economic Characteristics of India
3.4 HIV/AIDS in Indian Context

4 Churches and Church-related Organizations and HIV/AIDS
4.1 The Role of Churches in the Struggle against HIV/AIDS
4.1.1 Churches and their Specific Advantages in the Struggle against HIV/AIDS
4.1.2 Churches and their Role in the Struggle against HIV/AIDS
4.2 The Churches and their Theological Perspectives on HIV/AIDS
4.2.1 HIV/AIDS in the Background of Biblical Statements
4.2.2 Ecumenical Theological Understanding of Sin Related to HIV/AIDS
4.2.3 Ecumenical Theological Understanding of Punishment and Forgiveness
Related to HIV/AIDS
4.3 Church as a Healing Community and Pastoral Care
4.4 Selected Ethical Perspectives on HIV/AIDS of the Ecumenical
Community
4.5 Transmission of the Ethical and Theological Perspectives into the
Social Environment
4.5.1 Stigmatization and Discrimination
4.5.2 Respect of a Person – Confidentiality
4.5.3 Gender Issues
4.5.4 Children and Young People
4.5.5 Sex Education
4.5.6 The Use of Condoms
4.5.7 Poverty and Economic Justice
4.5.8 Human Rights on the Background of HIV/AIDS
4.5.8.1 Access to Anti-Retroviral Medication – a Human Right
4.6 Summary

5 Churches, Church Relates Organizations and Selected
Organizations Dealing with HIV/AIDS in Ethiopia and India
5.1 Ethiopian Churches, Church-related Organizations and
Secular Organizations Dealing with HIV/AIDS Issues –Table 1
5.2 Indian Churches, Church-related Organizations and Secular
Organizations dealing with HIV/AIDS Issues – Table 2

6 Implmented Strategies and Activities for Responding to the
HIV/AIDS in Ethiopia and India - Challenges and Limitations
6.1 Ethiopian Churches and Organizations Interviewed
6.1.1 Identified Advantages of Churches in Working with HIV/AIDS Compared
to Secular Organizations
6.1.2 Identified Disadvantages of Churches in Working with HIV/AIDS
Compared to Secular Organizations
6.1.3 General Objectives Mentioned by Churches and Church-related
Organizations Interviewed
6.1.4 Target Groups Mentioned by the Churches and Church-related
Organizations
6.1.5 Practical Aims and HIV/AIDS Programmes and Strategies Mentioned
by the Churches and Church-related Organizations
6.1.5.1 Prevention Sector
6.1.5.2 Care and Support Sector
6.1.6 Stigmatization and Discrimination
6.1.7 Mainstreaming HIV/AIDS
6.1.8 Advocacy, Lobbying and Networking
6.1.9 Monitoring and Evaluation (hereafter, M&E)
6.1.10 Identified Problems in General
6.1.11 The Role of Expatriates in the Churches
6.2 Indian Churches and Organizations Interviewed
6.2.1 Identified Advantages of Churches in Working with HIV/AIDS Compared
to Secular Organizations
6.2.2 Identified Disadvantages of Churches in Working with HIV/AIDS
Compared to Secular Organization
6.2.3 General Objectives Mentioned by the Churches and Church Institutions
Interviewed
6.2.4 Target Groups Mentioned by the Churches and Church-related
Organizations
6.2.5 Practical Aims and HIV/AIDS Programmes and Strategies Mentioned
by the Churches and Church-related Organizations
6.2.6.1 Prevention sector
6.2.6.2 Care and support sector
6.2.6 Stigmatization and Discrimination
6.2.7 Mainstreaming HIV/AIDS
6.2.8 Advocacy, Lobbying and Networking
6.2.9 Monitoring and Evaluation (M&E)
6.2.10 Identified Problems in General

7 Conclusion and Recommendations.

References

Appendix

Declaration

Dankesworte/Acknowledgements

List of Tables

Table 1 Ethiopian Churches, church-related Organizations and Secular Organizations dealing with HIV/AIDS

Table 2 Indian Churches, Church-related Organizations and Secular Organizations dealing with HIV/AIDS Issues

Table 3 Objectives of Ethiopian Churches and Church-related Organizations dealing

with HIV/AIDS

Table 4 Target Groups of Ethiopian Churches and Church-related Organizations

Table 5 Prevention Programmes of Ethiopian Churches and Church-related

Organization.

Table 6 Care and Support Programmes of Ethiopian Churches and Church-related Organizations

Table 7 Objectives of Indian Churches and Church-related Organizations dealing

with HIV/AIDS

Table 8 Target Groups of Indian Churches and Church-related Organizations

Table 9 Prevention Programmes of the Indian Churches and Church-related

Organizations

Table 10 Care and Support Programmes of Indian Churches and Church-related Organizations

1 Introduction

The Acquired Immunodeficiency Syndrome (hereafter, AIDS) pandemic has changed many parts of the world in just a short time despite efforts aimed at controlling it. Human Immunodeficiency Virus (hereafter, HIV)/AIDS is predominantly a sexually transmitted disease that causes illness and death. The groups most at risk are those between 15 and 49 years, often described as the “sexually active”, who are the most reproductive people in society and the backbone of the productive forces of any country. The particularities of this disease are not only the large number of victims, but also the suffering of those affected. AIDS is related to two deep dimensions of the human existence: sexuality and death. The impact of HIV/AIDS is multi-dimensional as the disease affects social, economic, political, psychological, cultural, ethical and religious areas.

Additionally, the connection of sexuality and death is often linked to the questions of guilt and innocence, chance and causality. Wherever such deep dimensions of human existence are raised, religion may be called upon. The questions of the why and whereto are not purely questions of medical science but often involve transcendence and therefore religion. HIV/AIDS and the approach of churches and church-related organizations is a complex issue. In many countries, congregations and parishes are seen to be in the forefront of effective contributions to sexual education and prevention, especially in the form of care and support programmes. AIDS thus mobilizes churches as healing communities. On the other hand, churches are often accused of being a sleeping giant, of promoting stigmatization and discrimination based on fear and prejudices, of reducing issues related to AIDS to simplistic, rigid sexual and moral judgements. They are said to be hindering appropriate preventative measures and leaving those “out there” to the consequences of their own debauchery and sin. The German “Fachkreis Ethik”, a working group of the German Action Campaign against AIDS, Malaria and Tuberculosis ^[1], states that churches should recognize that they cannot dissociate themselves from the HIV/AIDS problem, taking into consideration the fact that 25 to 30 million of the 40 million people living with HIV/AIDS (hereafter, PLWHA) are baptised Christians. Therefore, AIDS is a central problem of the church and cannot be considered as a problem of some people “outside”, people living in poverty, some prostitutes or drug users, as has sometimes been claimed in the past. The slogans “we, the Christians – as well as the churches – ‘have’ AIDS” or “the body of Christ has AIDS”^[2] indicate that churches are willing to focus on the global struggle against HIV/AIDS.^[3]

This study examines the content and the implementation of church programmes on HIV/AIDS prevention, care and support, focusing on Ethiopia and Southern India. It is guided by the assumption that the approach to HIV/AIDS of parishes and church-related organizations might differ from the approach recommended by umbrella church organizations such as the World Council of Churches (hereafter, WCC). It is also assumed that church-related HIV/AIDS programmes differ somewhat from those of secular organizations, although this is not a comparative study. Additionally, this study attempts to answer the question of whether the church-based approaches are more or less helpful to the beneficiaries than other approaches. Finally, the study’s investigation focuses on the question: Do the HIV/AIDS programmes of churches and church-related organizations contribute to an effective reduction of the pandemic, or, if not, what changes could be suggested?

The purpose of this study is to discuss the involvement and approaches of churches and church-related organizations in the struggle against HIV/AIDS on the basis of the following research questions:

- How do churches and church-related organizations approach the HIV/AIDS pandemic under the aspect of ethical, social and theological issues?
- What kinds of strategies, concepts and activities are being developed by churches and church-related organizations in the fight against HIV/AIDS in Ethiopia and India?

How do they correspond with their theological framework?

- Through which measures can churches and church-related organizations improve their performance in the struggle against HIV/AIDS?

The research is informed by the following hypotheses:

The church and church-related organizations have a specific, theology-based approach to HIV/AIDS programmes.

The theology-based approaches may not correspond with the practical HIV/AIDS approaches of churches at grass-roots level.

Research Methodology

The research was conducted in Ethiopia and India.

Ethiopia : Ethiopia was chosen for this study because nearly its entire population belongs to religious communities; just under 50 percent of Ethiopians are members of the so-called Christian mainline churches and newly appeared charismatic movements. One of the fastest growing churches worldwide can be found in Ethiopia, the Lutheran-based former mission church, the “Ethiopian Evangelical Church Mekane Yesus” (hereafter, EECMY), which is a national church operating in almost all regions of Ethiopia. The other half of the population belongs to the Islamic community, and few practise traditional religions, particularly in the South. The government tends to neglect the seriousness of the increasing HIV/AIDS prevalence, which was estimated at 4.4% in 2003. Due to this fact, churches and religious communities face a specific challenge in the struggle against HIV/AIDS.

India : India was selected for its contrasts with Ethiopia. Just 2.7% of its population of one billion belong to Christian churches. Christians are in the minority and therefore face specific challenges. Moreover, India is still influenced by the caste system. Most of the Christians belong to the Dalits.^[4] Specific attention to this issue in relation to the stigmatization of PLWHA is needed. India has the largest total number of HIV/AIDS-infected people globally; the estimated number is five to six million. In relation to the vast population, the HIV/AIDS prevalence is, however, very low. Due to this fact, the Indian government has only just started to respond to the problems related to HIV/AIDS.

It was furthermore of particular interest to the researcher to study some of those churches which maintain partnership relations with German churches.

Instrumentation and Data Collection Techniques

This study makes use of both primary and secondary data. The methodological approach to the topic is a combination of qualitative research and literature analysis.

Data Collection, Arrangement of Interviews with Experts, Observations, and Analysis of Collected Data

The collection of primary data focused particularly on people in charge of HIV/AIDS desks. The data was collected using structured interviews with experts from churches and church-related organizations. The interviews were divided into two parts. A structured questionnaire constituted the first part, after which an informal discussion focused on the personal attitudes of the expert in charge of the HIV/AIDS desk towards HIV/AIDS programmes. The research results were analysed qualitatively, paying particular regard to the identities of persons responsible for the HIV/AIDS area.

The researcher also attended workshops and seminaries on the topic of HIV/AIDS conducted by churches and church-related organizations. This was done in order to collect information about the concrete content of the trainings, to find out if they corresponded with training manuals, and to study the implementation of HIV/AIDS programmes. Informal discussions with church leaders and managers of church-related institutions provided complementary information about the objectives and implementations of their HIV/AIDS programmes.

Review of Current Literature and the Development of this Research

A general increase in literature on HIV/AIDS issues can be observed; there is also an extensive coverage of the churches’ response to the disease. Most of them have no scientific background. Some solitary studies can be found, edited by church-related organizations. However, most of them were published in the 1990s. However, the secondary data collections were mostly based on so-called grey literature, that is, studies, web pages, former research, magazines, newspapers, journals, and activity reports of churches. Internal assessments of churches or church-related organizations concerned supplemented the literature. Reports and studies by relevant UN agencies and the WCC provided secondary data. General literature on HIV/AIDS provided additional information on the topic under study.

2 HIV/AIDS - Basic Facts and Problems

“Our youth are dying like flies due to the HIV/AIDS pandemic”, stated a Lutheran Bishop from Swaziland in 2004^[5]. What began as a disease infecting homosexual men in the United States in the early 1980s has become a global crisis that is decimating populations – especially women, young adults and children, mainly in sub-Saharan Africa, but also with steep increases occurring in East and Central Asia and Eastern Europe.^[6]

2.1 Basic Facts and Background on HIV/AIDS

AIDS is a syndrome with various symptoms and clinical pictures, caused by the weakening of the immune system as a result of an infection with one of the two types of the HI virus, HIV-1 and HIV-2. It is the final stage of the HIV disease and is characterised by the appearance of a multitude of opportunistic infections, resulting from the breakdown of the immune system.^[7] These opportunistic infections include pneumonia, diarrhoea and skin diseases, Kaposi’s sarcoma, and tuberculosis, the latter of which is mainly found in Africa.

All forms of HIV can be transmitted in four different ways:

- sexual intercourse (anal, vaginal, oral) through semen and vaginal discharge;
- contaminated blood or blood products;
- contaminated syringes and instruments;
- mother-to-child transmission (hereafter, MTCT) or “vertical” transmission from an HIV-infected woman to the baby in the uterus, during childbirth or through breastfeeding.

The risk of transmission lies substantially lower than is widely assumed. It is 0.01% for a one-time sexual contact from an infected person to a non-infected person.^[8] The risk is higher, about 1%, when HIV is already in an advanced stage or when a person has another sexually transmitted disease (hereafter, STD). The risk of getting an HIV infection is up to 10-fold higher for people with STDs. Almost 87% of all HIV-infections in Africa are transmitted through heterosexual intercourse, while in industrialized countries, only 24% of all HIV-infections are transmitted that way.

2.2 Main Problems related to the HIV/AIDS Disease

In spite of intensive biomedical research, no cure has yet been found for the immune deficiency caused by the HIV infection. Continuing attempts to develop an effective vaccine or prophylaxis against the HIV infection have so far been unsuccessful till today.

However, there have been major advances in clinical treatment in regard to prolonging life and mitigating the disease. Since 1996, anti-retroviral therapies have been used when patients’ CD4^[9] cell counts fall and their immune systems fail. Anti-retroviral drugs (hereafter, ARVs) act specifically against the HI virus. The introduction of combination ARV therapy has resulted in declining mortality rates from HIV, but only among the rich in industrialized countries. High prices for drugs, patent protection for branded drugs, inadequate infrastructure and lack of training of healthcare workers can be seen as blocking access to ARV in many of the poor countries. Despite the increasing awareness of ethical and moral implications of inequalities in AIDS treatment between poor and rich countries and the substantial reduction of prices for ARVs, only 800 000 people worldwide take ARV drugs, around 500 000 of whom live in industrialized countries.^[10] However, the demand to increase access to ARVs for PLWHA in developing countries has been voiced ever more clearly by AIDS activists, scientists and civil society.

Due to their weakened immune systems, PLWHA are more likely to catch various opportunistic diseases. The treatment of many opportunistic infections related to HIV/AIDS, which occur more easily without ARV treatment, is very costly and thus often not affordable to people in developing countries. Tuberculosis (hereafter, TB) is the most common opportunistic infection related to HIV/AIDS. In South Africa, approximately 50 percent of TB patients are infected with HIV^[11], and the tendency is rising.

Another specific problem in connection with HIV/AIDS is the high percentage of AIDS orphans.^[12] More than 14 million children under the age of 15 are AIDS orphans, 12 million of whom live in sub-Saharan Africa. USAID (U.S. Agency for International Development) and UNAIDS estimate that by the year 2010, the number of AIDS orphans will have risen to more than 25 million, or even 40 million.

AIDS is an infection with a high percentage (25 per cent, UNICEF) of mother-to-child transmission (hereafter, MTCT), also called vertical transmission. Around one half of the transmissions occur during pregnancy and birth, the other half during the breastfeeding period, if no medication is available.

2.3 HIV/AIDS Globally - Epidemiological Data

In 2004, the total number of people living with HIV reached the highest level ever estimated, contradicting former assumptions that the HIV/AIDS pandemic had already crossed its peak. In December 2004, the “Global Summary of the AIDS Epidemic” of UNAIDS^[13] released HIV data on global, regional and national levels for 2004. That year, approximately 39.4 million (35.9 – 44.3 million) people in total were living with HIV worldwide. Of those, 37.2 million (33.8 – 41.7 million) were adults^[14] and 2.2 million (2.0 – 2.6 million) children under 15 years. Women accounted to 17.6 million (16.3 – 19.5 million). In 2004, 4.9 million (4.3 – 6.4 million) people were newly infected with HIV, out of whom 4.3 million (3.7 – 5.7 million) were adults and 640 000 (570 000 – 750 000) children under 15 years. In the same year, 3.1 million (2.8 – 3.5 million) people in total were killed by the global AIDS epidemic, comprising 2.6 million (2.3 – 2.9 million) adults and 510 000 (460 000 – 600 000) children under 15 years.

3 Country Profiles of Ethiopia and India Regarding HIV/AIDS

3.1 Political, Demographic and Socio-Economic Characteristics of Ethiopia

Ethiopia is located in the Horn of Africa. In terms of population, it is one of the most populous countries in Africa. Ethiopia represents a melting-pot of ancient Middle Eastern and African cultures, reflected by its religious, ethnic and language composition. In 2004, the Amhara and Oromo population groups represented the majority; they accounted for about 60% of the total population of 73 million^[15], of which 54.4 million (85%) people lived in rural areas. The annual population growth rate is about 2.4% in 2005; 44% of the population is below 14 years, while 43% are between 15 and 49 years of age^[16]. In 2003, the adult literacy rate was around 42% and primary school enrolment was less than 27% in 1999. 31% of the entire population lived on less than one US-dollar a day; the GNI (Gross National Income) per capita amounted to US$ 110.00 in 2004^[17]. Ethiopia belongs to the world’s least developed countries according to the Human Development Index, ranking 170th of 177 countries in total. Agriculture dominates the Ethiopian economy, accounting for about 50% of the GDP, 65% of all exports and 85% of employment. The main cash and industrial crops are coffee, oil seeds, pulses, cotton, sisal, tobacco, fruits and sugar cane. The manufacturing products are textiles, foodstuff, beverages, cement, leather and leather products, wood, metallic products and others.

The National Health Service coverage is below 51% with wide disparities between rural and urban areas and between different regions. Fewer than 20% of Ethiopians live within a two-hour walk of a modern healthcare facility. One fifth of Ethiopian children die before their fifth birthday, often due to communicable diseases such as diarrhoea, measles, malaria, or respiratory infections. Only 12% of the rural and 26% of the urban population have access to safe drinking water and proper sanitation facilities. 47% of children under five years are underweight. The mortality rate of children below five years of age is 9.7%, one of the highest in the world, and a mere 2% of all deliveries are attended to by trained health personnel. Life expectancy at birth is 52 years.

3.2 HIV/AIDS in Ethiopian Context

Since 1996, a national report entitled “AIDS in Ethiopia” has been published by the Ministry of Health (hereafter, MOH) every two years. It provides a useful overview of the current situation in Ethiopia in addition to the “Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections - Ethiopia” by UNAIDS, UNICEF and WHO. The true number of AIDS cases is unknown, mainly because they are not being properly reported. Some people have no access to health services or hospital HIV/AIDS care. As a consequence, people with an HIV infection may die of an opportunistic disease before they are diagnosed as having AIDS. Patients’ records are also not kept properly. Finally, a little-developed reporting culture in the country is one of the reasons why information about HIV/AIDS patients cannot be kept properly.

In 1989, the prevalence of HIV among adults was 2.7%. It increased rapidly in the 1990s. In 2001, the estimation of the national HIV prevalence rate was based on data from 34 sentinel surveillance sites of which 28 are urban and six rural. The national HIV prevalence rate was estimated to be 10.6%, representing more than two million people. In 2002, the prevalence rate indicated 6.6%. Out of the more than 23.000 national sentinel surveillance samples obtained 8.2% (4.1% rural and 12% urban) were found to be positive in 2003. The estimated national adult HIV prevalence in 2003 was 4.4% (2.8% - 6.6%), 1.5 million.^[18], perhaps an indication for a possible stabilization of the epidemic, or a result of more extensive surveillance data. In 2002, the urban HIV/AIDS prevalence rate was 13.7%, while that for rural areas was 3.7%. The prevalence rate for Addis Ababa is 15.6%. The highest prevalence of HIV occurs among people of 15 to 24 years of age, representing “recent infections”. The age and gender distribution of reported AIDS cases shows that about 91% of infections occur among adults between 15 and 49 years. The data also show that the number of females infected between 15 and 19 years is much higher than the number of males in the same age group. In 2001, 1.2 million orphans were being reported. The major avenue of transmission of HIV infections in Ethiopia is heterosexual intercourse. Exact figures are lacking.^[19] Various contributory factors to the spread of HIV/AIDS can be observed: Poverty and low health status of the majority of the population give fertile ground for the spread of HIV/AIDS. A high unemployment rate, low return from informal sector income-generating projects, and economic migrants lead to high-risk behaviour such as prostitution. Moreover, a study of the urban population found that 22% of adult men and 8% of adult women are engaged in sex with multiple partners^[20], which increases the risk of acquiring the virus. Unprotected sex is very popular and contributes to the spread of HIV. Until today, the Ethiopian government as well as the population tend to deny the extent of the epidemic. Denial and ignorance lead to silence, and silence supports the spread of HIV/AIDS. According to the “Baseline Survey on Harmful Traditional Practices in Ethiopia”, the prevalence of female genital mutilation in the country accounts to 78%. This harmful tradition practised for a long time has a high potential of spreading HIV. It is only since 2004 that female genital mutilation is forbidden by law in Ethiopia. Consequently, women at a reproductive age are normally circumcised. Dry sex, which increases the risk of HIV transmission for women, is very common among circumcised women. The presence of sexually transmitted diseases (STDs) increases the risk of HIV/AIDS transmission. The risk is about 1% when HIV is already in a further stage, or when one person has a sexually transmitted disease. The risk of getting an HIV infection is up to 10-fold for people with STDs. The unadjusted syphilis prevalence among ANC attendees in 2003 was 1.8 percent.^[21] Women are more vulnerable to HIV infections. The subordinate position of women in Ethiopia, the inability to negotiate on safe sex, the young age of girls at first marriage, violence, abduction, and female genital mutilation all enhance the vulnerability of women in Ethiopia. Furthermore, the Ethiopian society tends to be very mobile for various reasons, for instance to search employment. Commercial sex workers (hereafter, CSW), truck drivers, seasonal workers, traders and members of the military belong to these very mobile groups. Urbanization, war and conflicts as well as recurrent droughts contribute to mobility; internal displacement, migration and extended families, traditional behaviour patterns and social control mechanisms do not function on the same level as in the past. Migrants, however, have a higher risk of getting HIV-infected. Additionally, the months-long absence of men from their family contributes to a risky behaviour and finally to the spread of HIV in the villages when migrant workers come back home to their partners and often do not know that they are HIV-positive.

In response to HIV/AIDS, the Federal Government of Ethiopia has developed important policy and strategic instruments to curb the devastating impact of HIV/AIDS on human and social capital development.^[22] Two medium-term plans (1987-1992 and 1992-1997) focused on public awareness, the establishment of laboratory services, surveillance of HIV and training of health workers, put emphasis on interventions to stop the spread of HIV, and adopted a multi-sectoral approach to mobilize a widespread effort against AIDS through the decentralization of AIDS/STD prevention and control activities. The federal government of Ethiopia has produced and implemented guidelines on sentinel surveillance and counselling, and also launched a national policy on HIV/AIDS in 1998. The policy includes the following:

encouraging people to maintain faithful sexual relations with only one partner;

promoting the use of condoms in situations with a risk of HIV transmission;

minimizing other unsafe practices such as illegal injections, harmful traditional procedures and drug addiction;

ensuring safe medical practices to protect against HIV transmissions from patient to patient and from patient to healthcare provider;

ensuring the human rights of PLWHA.

The National AIDS Council was established in 2000 to intensify and coordinate the multi-sectoral response to the epidemic. The council is chaired by the Ethiopian president and consists of members of sector ministries, regional states, NGOs, religious bodies and representatives from civil society and PLWHA. Later, a National AIDS Council Secretariat will be established under the prime minister’s office, and the government has developed a strategic framework for the national response to HIV/AIDS in Ethiopia that covers the period 2001-2005. The major areas addressed are: prevention of the transmission, development of voluntary counselling and testing, alleviation of personal and social impact of HIV/AIDS development, and promotion of HIV/AIDS operational research and monitoring. Finally, AIDS councils have been established at the national, regional and sub-regional levels with secretariats supporting them.

3.3 Political, Demographic and Socio-Economic Characteristics of India

India has an area of 3,287,263 sq km. The capital of India is New Delhi with around 9.8 million inhabitants; the country’s largest city is Mumbai (formerly Bombay) with around 12 million people. Chennai (formerly Madras) has 4.2 million people, according to the Indian Census 2001.^[23] India is one of the world’s most populous countries, with a population of 1.06 billion estimated for 2003^[24], and an average population density of 325 persons per sq km in 2001. An estimated 72% of India’s inhabitants live in rural areas. The estimated annual population growth rate in 2003 was 1.6%^[25]. 32.2% of the population are below 14 years, while 63% are between 15 and 64 years of age. The average age was 24.1 years in 2002^[26]. 47% of the children under the age of five are malnourished. The life expectancy at birth is 63 years. The illiteracy rate in total is 39%. 46% of the women are illiterate and the gross primary enrolment of school age population is 99%^[27]. 29% of the population live on less than one US$ per day; an estimated total number of 291 million of the population live in absolute poverty. The GDP per capita was around US$ 540 in 2002. India ranks 127th of the Human Development Index.

There are 28 States and seven Union Territories in India. The main ethnic groups are Indo-Aryan (72%), Dravidian (25%) and Mongoloid (3%). India is a multilingual society with 18 principal languages recognised by the constitution. A large share of people speaks Hindi (38%), while English is the predominant business language. Religion – deeply rooted in history – is very important in India; Hinduism and Buddhism both originated here. The major religious groups are Hindus (81.3%), Muslims (12%), Christians (2.6%), Sikh (1.9%) and others, including Buddhist, Jain and Parsi. The social and economic framework for the life of the people in India is historically formed by the caste-system. The values of the caste system are still adhered to, particularly in rural areas. The caste system encompasses a complex order of social groups on the basis of ritual purity in which the social and economic rights of each individual caste are predetermined by birth. A person is born into a caste and remains within it until death. There are four principle castes: the Brahmins, the Kshatrias, the Vysias and the Sudras. At the bottom of the system are the outcastes, the untouchables. The outcastes mostly work for the other groups.

Since independence, the Indian economy has struggled hard to improve its pace of development. Notably in the past few years, the cities have undergone tremendous infrastructural up-gradation. In most parts of rural India, the situation is, however, very different.^[28] More than 58% of the country’s population depends on agriculture, a sector producing just 22% of the GDP.^[29] India is the largest producer of tea, jute and jute-like fibre. The industrial sector of India produces 26.4% of the GDP and the manufacturing sector 15.6% of the GDP^[30]. The main export commodities are textile goods, agricultural goods, gems and jewellery, engineering goods, software services and technology, chemicals, and leather products. The service sector is the highest contributor to the total GDP with 50.7%. India’s large number of English-speaking, skilled manpower has made the country a major exporter of software services and software workers.

3.4 HIV/AIDS in Indian Context

The National AIDS Control Organization (hereafter, NACO), the Ministry of Health and others have been updating HIV estimates for the country every year since 1998. The number of HIV infections in India is, however, difficult to determine and subject to ongoing controversy. India’s prevalence estimates are solely based on sentinel surveillance conducted at 455 public sites in 2003.^[31] The country has no overall national information system to collect HIV testing information from the private sector, which provides 80% of health care in the country. Therefore, figures out of the “Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections - India”^[32] by UNAIDS, UNICEF and WHO are additionally used to give an overview about the HIV/AIDS prevalence in India.

The first case of AIDS in India was detected in a female commercial sex worker in 1986 in Chennai, Tamil Nadu. In the initial stage, there was a sense of denial and complacency in India’s response to HIV/AIDS. India was considered to be “immune” to HIV/AIDS due to its cultural, moral and religious norms.^[33] However, in 1987, NACO launched programme activities covering surveillance, screening of blood and blood products and health education, as well as the formulation of policies, prevention and control programmes. The government launched a strategic plan for HIV/AIDS prevention under the National AIDS Control Project in 1992. The project established the administrative and technical basis for programme management and also set up state AIDS bodies in 25 states and seven union territories. The project improved blood safety. India has had a sharp increase in the estimated number of HIV infections, from a few thousand in the early 1990s to 3.6 million in the late 1990s. In 2003, it was estimated that 5.1 million (2.5 million – 8.5 million) children and adults were living with HIV/AIDS. Of these, around 600 000 are in need of antiretroviral therapy (hereafter, ART) but less than 30 000 are currently receiving it. The government of India launched the national antiretroviral programme in April 2004^[34]. In South and South-East Asia, 30% of adults (up from 28% two years ago) and 40% of young people living with HIV are women and girls. In 2004, women accounted for more than one quarter of new HIV infections in India, according to estimates, and 90% of those who test positive at antenatal clinics say they are in single, long-term relationships.^[35] Around 38% of PLWHA were women. In 2001, the number of orphaned children was estimated at 1.2 million. Although children are not yet being orphaned by HIV/AIDS on a large scale in most cities, studies have shown that the problem of orphans in some urban slum areas of India is already severe.^[36] The UN estimates that there were 2.7 million AIDS-related deaths in India between 1980 and 2000.^[37] The national adult HIV prevalence is 0.9%; India continues to be in the category of low prevalence countries with an overall prevalence of less than 1%.

The spread of HIV within the country is as diverse as the societal patterns between its different regions, states and metropolitan areas. In fact, India’s epidemic is made up of a number of epidemics, and in some places they occur within the same state. The epidemics vary from states with mainly heterosexual transmission of HIV, to states where injecting drug use is the main route of HIV transmission.^[38] Of the 35 states of India, six states, four in southern India (Andra Pradesh, Tamil Nadu, Maharashtra, Karnataka) and two in north-eastern India (Manipur and Nagaland), have generated epidemics with HIV prevalence rates of above 1% among pregnant women. These six states account for nearly 80% of all reported AIDS cases in the country. In the southern states, heterosexual transmission accounts for the majority of the reported cases, whereas in the north-eastern states of Manipur und Nagaland, injecting drug use is the predominant mode of transmission, where the prevalence among intravenous drug users (hereafter, IDUs) was 56% in 2003. More than 50% of the CSWs in urban southern states are infected.^[39] In total, the epidemic is primarily (85.69%) spread by sexual contacts, both homo- and heterosexual, 2.7% of the transmissions are MTCT, 2.57% occur through blood and blood products, and about 2.4% through IDUs in 2003.^[40] Around 60% of PLWHA suffer from opportunistic infections, of which the number one is tuberculosis.

It is estimated that 70% of the CSWs in Mumbai are HIV-positive. Although HIV/AIDS is still largely concentrated in at-risk populations, including CSWs^[41], IDUs, and truck drivers, the surveillance data suggests that the epidemic is moving beyond these groups in some regions and into the general population. It is also moving from urban to rural districts.^[42]

A National Behavioural Surveillance Survey (hereafter, BSS) was conducted by an external agency amongst 3832 people aged 15-49 years from all over the country in 2001.^[43] Overall, 76.1% (82.4% males, 70% females) had heard of HIV/AIDS before. More than three out of every four respondents were aware that HIV/AIDS is transmitted through sexual intercourse. The awareness rates were higher among the urban residents. 46.8% in the entire country were aware of the two important methods of prevention of transmission, i.e. consistent condom use and a sexual relationship with a faithful and uninfected partner. The proportion of respondents aware of both methods was lowest among rural females. In general, the findings of BSS show that there are significant differences concerning the awareness levels regarding HIV/AIDS/STDs. In most instances, females and rural residents were more disadvantaged compared to their counterparts.^[44]

In India, AIDS is perceived as a disease of “others” - of people living at the margins of society, whose lifestyles are considered perverted and sinful. Discrimination, stigmatisation and denial are the outcomes of such values, affecting life in families, communities, workplaces, schools and health care settings.^[45] Social reactions to people with AIDS have mostly been negative. For example, in one study, 36% of the respondents felt it would be better if infected people killed themselves; the same percentage believed that infected people deserved their fate. Also, 34% said they would not associate with people with AIDS, and one fifth stated that AIDS was a punishment from God.^[46] The health care sector has generally been the most conspicuous context for HIV/AIDS-related discrimination, stigma and denial. Negative attitudes from health care staff have generated anxiety and fear among many people living with HIV and AIDS. As a result, many keep their status secret, fearing still worse treatment from others. Women are often blamed by their parents and in-laws for infecting their husbands, or for not controlling their partners’ urges to have sex with other women. On 16 February 2005, “The Hindu” released an article under the headline “HIV-positive women killed”. An HIV-positive woman had allegedly been killed by her relatives at Dharasana village in Gujarat’s Valsad district, reported the police.^[47]

People in marginalized groups (CSWs, transgender and gay men) are often doubly stigmatised if they have a positive HIV status.^[48]

4 Churches and Church-related Organizations and HIV/AIDS

It is impossible to mention in this thesis all theological directions and trends of different churches concerning their approaches to the HIV/AIDS pandemic. The focus therefore lies on the theological and ethical framework of the HIV/AIDS study “Facing AIDS, The Challenge, the Churches’ Response”, published in 1997, reprinted in 2001 by the WCC, which comprises more than 340 member churches in about 100 countries. The publication is based on a three-year, broadly-based study with the aim to examine the theological and ethical issues raised by AIDS, to research an appropriate response to church members who are directly affected, and to identify issues of human rights directly related to the spread of HIV/AIDS. The study is commended to the churches for reflection and appropriate action.

The Roman Catholic Church is not a member church of the WCC, but works closely together with the WCC council. Nevertheless, most of the Ethiopian and Indian churches mentioned in the following section are member churches of the WCC. In addition, some theological statements of a consultation on “HIV/AIDS: A Challenge to Theological Education”, held by medical personnel, theology teachers, and pastors of various Indian Christian churches in Bangalore in the end of 2003 will be used to complement the theological and ethical framework regarding AIDS.

4.1 The Role of Churches in the Struggle against HIV/AIDS

4.1.1 Churches and their Specific Advantages in the Struggle against HIV/AIDS

Churches and church-related organisations have a unique possibility to contribute to the struggle against HIV/AIDS.^[49] They constitute a microcosm of society and are an integral part of life and society in many parts of the world. Church networks cover even remote areas in rural regions in all countries worldwide; they are rooted in local structures and additionally have an autonomous organizational structure, and therefore a good opportunity for social mobilization. Like no other institution, they have the possibility to reach the people on a weekly basis through their Sunday services. They have the largest constituency of people and an enviable infrastructure, extending from the international community to the marginalized. Their credibility is very high because of their presence at grassroots level and their involvement with the people at nearly every aspect of their lives. There is a strong social trust and confidence in churches. The influence of church leaders is considerable. Churches have a particular resource in their parishes, namely the voluntary lay people who care e.g. for the sick and for orphans. Churches provide a holistic ministry for those infected with and affected by HIV/AIDS, addressing the physical, spiritual, and emotional well-being of the individual and the community.^[50]

Therefore, churches have a high potential in community mobilization. Churches and church-related organizations operate alongside governments, providing the same major services and often filling the gaps where governments fail to act. In addition to spiritual care, counselling, community and social life, and the provision of preaching places, churches provide an immense field of social services. Their outreach projects cover the medical sector and social welfare, education from primary education to university level, justice, environmental protection, and peacekeeping. Additionally, churches are involved in development programmes such as agricultural projects, poverty alleviation schemes, feeding projects, empowerment and capacity building projects, and homeless shelters. A UNICEF report summarizes the role of churches in developing countries: “Religion plays a central, integrating role in social and cultural life in most developing countries … there are many more religious leaders than health workers. They are in closer and regular contact with all age groups in society and their voice is highly respected. In traditional communities, religious leaders are often more influential than local government officials or secular community leaders.”^[51] Therefore, churches are able to cover all fields in the struggle against HIV/AIDS, in the prevention sector through education, information and awareness, and in the care and support sector through medical care, testing and spiritual counselling. Finally, advocacy and lobbying for PLWHA is an important area in which the church is able to operate.

4.1.2 Churches and their Role in the Struggle against HIV/AIDS

Despite the opportunities of the churches in the combat against HIV/AIDS, “AIDS and the churches” is a complex subject. Many questions still have to be answered. Are churches, especially at the grass-roots level, really committed to the topic HIV/AIDS, or do they get stuck in their often rigid sexual morality and the rejection of preventative measures? Is the pandemic a problem which comes from the outside, or is it part of the church? Does the church debate the theological and ethical background of HIV/AIDS-related issues? For many, churches are part of the problem rather than of the solution. Churches often understand themselves as keepers of rigid sexual morals, so that to many church members, confronted with the HIV/AIDS topic, not diseases come to mind in the first place, but sin, debauchery, homosexuals, and promiscuity. Consequently, a fruitful soil is being created for prejudices, stigmatization and discrimination of affected people. On this background, topics related to HIV/AIDS were a taboo. Thus, the study by the WCC on HIV/AIDS states that the response of the churches has by and large been inadequate, and in some cases has made the problem even worse.^[52] Churches, especially at the grass-roots level, have indeed significant difficulties in dealing constructively with the topic HIV/AIDS.

4.2 The Churches and their Theological Perspectives on HIV/AIDS

4.2.1 HIV/AIDS against the Background of Biblical Statements

Although HIV/AIDS is no disease of ancient history, various biblical statements are cited here to back up the commitment on HIV/AIDS issues of churches. One important of these might be: “If one part is suffering, all parts are suffering” (1. Cor. 12:26). The verses in Isaiah 58:6ff emphasize that people who care for the poor and show solidarity stand under a particular blessing of God^[53]. Jesus’ openness to people of all kinds, without barriers of class, race or gender, is emphasized in the WCC study.^[54] God’s commitment towards all people is underlined in the WCC study by the following quotation: “Just as God in love accompanies all creation, so Jesus went among the poor, telling them that they were loved by God even if they had not been able to keep the law scrupulously… He healed Jewish lepers and a Roman soldier’s child… and unlike many holy men he did not shrink from the touch of a prostitute… Jesus incarnated the accessibility of God, who shows no partiality (Act 10:34, Rom. 2:11), but is open to all – rich and poor, sick or healthy, old or young.”^[55] M. Kurien characterizes Jesus’ earthly ministry^[56] while describing few typical actions. Churches are called to follow his example. Christ healed all diseases unconditionally (Mark 1:29-34), forgave sins (John 8:1-12, Luke 7:36-49; 15:11-32), and broke the stigma associated with leprosy by touching people with leprosy and restoring them to physical and social health (Mark 1:40-45; Luke 17:11-19). Here, leprosy is being compared to HIV/AIDS, as far as untouchability and taboo are concerned. Furthermore, the WCC study prompts the churches to stand in the tradition of Jesus, who “… was open for the religious establishment of his time”.^[57] He attended the synagogue and went to places where people were. All this has something to say to the churches about human being-in-relation. It speaks powerful against churches who declare that “nothing separates us from the love of God” (Rom. 8:39) – and then go on to set up barriers of their own between themselves and other people.^[58]

4.2.2 Ecumenical Theological Understanding of Sin Related to HIV/AIDS

In the Christian tradition since Augustin^[59], sexuality and sin have been closely associated. So the church discourse on a disease which is often sexually transmitted requires some reflections on the concept of sin and the ethical consequences to be derived from such a concept.

Churches and theologies express their acknowledgement of human sinfulness in various theories. The WCC study describes sin as distortion of being in a relationship with God or other human beings. Sins are actions which harm others or the natural world, and Christians bear their share of responsibility for them.^[60] The study argues that biblical faith understands sin relationally, namely as the breaking of our essential relatedness to God, to one another and to the rest of the creation. Sin, therefore, is alienation and estrangement, and infects everybody. Whether somebody has HIV or not, in the biblical sense all are sinners.^[61]

The orthodox churches stress that in dependence of God’s grace and humans’ will the human perfection is possible by spiritual growth. This theological theory is called “theosis”, which comprehends salvation from sin and the call to become holy and seek the union with God.

The protestant churches understand sin as the distortion of a right relationship with God, with other persons and the natural order, which can be only overcome through justification, the restoration of a right relationship with God, and through Jesus Christ. The WCC study stresses that the recognition of the common sinfulness makes spiritual growth possible, which leads to mutual forgiveness. First of all, Jesus was the one who forgave sins. When he died he took all human sins with him and “thus Christians see in his death the great affirmation that God forgives us”^[62] and set us newly in-relation. Concerning HIV/AIDS, the WCC study stresses that “there were many situations related to the spread of HIV/AIDS in which relationships have been hurt and may take time to recover.”^[63] True forgiveness does not mean “cheap grace” like D. Bonhoeffer called it, but “it is gracious and it does make continuing relationships possible.”^[64] The WCC study summarizes that churches have to become communities of the freely forgiven – communities of the healed which thus serve as places for healing others. Churches of the forgiven are not in a position to reject or withhold relations with others.^[65]

Sin and its association with sickness are often understood in an individualistic, moral sense in Christian communities. K.M. George, a principal of the Orthodox Theological Seminary in Kottayan, Kerala^[66], stresses that the often sexually transmitted and contagious HIV/AIDS that has moralistic connotations in ordinary human communities, and cancer that is not contagious and has no usual moralistic undertones, are both conditions of sickness and disintegration, and as such they are both the consequence of the sinful alienation of humanity from its source of being. He himself sees sin in a broader perspective and not on an individual level, and maintains the connection between sin and sickness at the level of entire humanity, similar to the description of the sin-sickness relation in the WCC study. G.M. Nalunnakkal^[67] succinctly says in his article: “The cause of AIDS is a virus, not sin.”^[68]

4.2.3 Ecumenical Theological Understanding of Punishment and Forgiveness Related to HIV/AIDS

The WCC study states that God forgives sins unconditionally; consequently, he is not the one who is concerned to punish. “Neither the biblical account of creation nor the understanding of God gives any basis for attributing to God the desire for punishment.”^[69] Beate Jabob from “Fachkreis Ethik”^[70] stresses that already the story of Job, which is described in a younger epoch of the Old Testament, has overcome the old oriental thinking of coherence between the acting of humans and what will happen to them consequently (e.g. an eye for an eye and a tooth for a tooth, Exodus 21:24). Job declines all theories of his friends who try to explain his bad situation as consequence of his personal guilt. Job is not aware of any personal guilt, on the contrary he accuses God. Jesus’ message emphasizes the responsibility of human action. However, two biblical stories in the gospel of Luke 13:3 and John 9: 1-3 describe that Jesus was invited to link sin with disaster, but he clearly refused. It is important to distinguish between punishment for an action and the natural outcome, the consequences of an action.^[71] In connection with HIV/AIDS it must be stressed that actual events always involve a complex constellation of causes and consequences, rather then a single cause and effect.^[72] A 13-year-old commercial sex worker who was sold by her parents due to poverty can neither be accused of being HIV-positive nor of spreading the disease. Labelling consequences as “punishment” is inappropriate. The complexity of societal structures, the economic condition, the cultural background as well as the ethical norm clarify why there is no simple process of cause and effect. Already in 1987, the WCC’s executive committee emphasized in a statement the need for affirming “that God deals with us in love and mercy and that we are therefore freed from simplistic moralizing about those who are attacked by the virus”. According to the WCC, “the terminology of punishment should be rejected in favour of an understanding of God in omnipresent, constant, loving relationship, no matter how much some of the actions of every one of us may grieve God.”^[73] To put the blame on PLWHA, which is often done in charismatic churches, should be condemned for theological reasons. Consequently, the WCC wishes that “Christ’s community of care is an environment in which risks can be taken; all members accept mutual vulnerability and stories may be shared in trust and commitment to each other.”^[74] The assumption for such a community is described as acceptance that the virus concerns the whole community. It is stressed that then the mutual relationship with those whose bodies are infected grows, and healing can begin. The study concludes that this process leads to real conversion for all involved.

The National Council of Churches in India (hereafter, NCCI) published the book “HIV/AIDS - A Handbook for the Church of India”^[75] for inter-church HIV/AIDS education in 2004. Manoj Kurian^[76] focuses on combating stigma and discrimination. M. Kurian underlines the interpretation implying that HIV/AIDS is punishment for sin, thereby pushing people who live with AIDS out of the “holy” community. Consequently, it is argued that this attitude not only contributes to “stigma and alienation but also makes the community sweep the issue under the carpet.”^[77] M. Kurian concludes that the truth is that we are all made in the image of God which means that discrimination is sin, and stigmatising any person is contrary to the will of God.^[78] M. Kurian underlines that the church has to accept that the virus affects the church as community, and that the church is not simply called to offer charity, but that it is challenged to see that as it belongs to the body of Christ the suffering caused by HIV/AIDS affects all of the church. He continues that the church must recognize that the crisis of AIDS is the church’s crisis and as such, “our church has AIDS”.^[79]

4.3 Church as a Healing Community and Pastoral Care

In sum, the WCC study stresses that the churches, by their very nature as the body of Christ, call on their members to become healing communities.^[80] What does this mean, taking into account that HIV/AIDS cannot be cured? Churches see their task as being an effective healing witness towards those affected. “The experience of love, acceptance and support within the community where God’s love is made manifest can be a powerful healing force”^[81], the WCC study underlines. Love is meant here not as an option for the community and individual, but a requirement, a demand due to the biblical background. On the basis of love and acceptance, “the HIV/AIDS pandemic is regarded as a unique opportunity to revive and reinforce the values of responsibility, sexual integrity, healthy relationship, human dignity and mutual respect.”^[82]

This love can be expressed through worship, which is a time to remember that humans are created in God’s image and can also help to remove barriers and prejudices and express God’s presence amidst his creation, the WCC study explains.

Furthermore, pastoral care and counselling are understood as a process of empowering the person to make own decisions. The goals of counselling are seen in helping infected persons to cope with their situation and to promote strategies for preventing and reducing HIV transmission. To create an environment of a healing community through pastoral care and counselling, the churches are asked to offer a healing space, an atmosphere of openness and acceptance.

In sum, it is stressed that the churches exercise a vital ministry through encouraging discussions and analysis of information, helping to identify problems, reflecting theological and ethical aspects, providing pastoral care and a healing community, recognizing the linkage between AIDS and poverty, and, finally, helping to safeguard human rights of PLWHA at national and international levels.

4.4 Selected Ethical Perspectives on HIV/AIDS of the Ecumenical Community

In comparison with the theological perspectives, which are mainly based on biblical statements and theological doctrines, the ethical perspectives are based on common as well as on Christian ethical concepts. Churches are confronted with many ethical questions concerning the HIV/AIDS pandemic. They are called to contribute to justice-oriented ethical perspectives in relation to HIV/AIDS. The HIV/AIDS pandemic is fuelled by certain structures of oppression and injustice. When people live in unjust structures, the chance to be infected by HIV is much higher than for people living in just structures. The former often do not have the ability to fight for their rights concerning education, health, work, social security and gender equality. Bishop Kamphaus from Limburg, Germany, formulates the responsibility for social justice and ethical perspectives in the following parable out of the New Testament: It is not enough to care for the one who was robbed and injured by thieves on the way to Jericho; it is more important to make the way safe to Jericho.^[83] In other words, a reflection on the issue of HIV/AIDS from a justice-oriented ethical perspective is demanded. The structural change for justice is essential for a sustainable fight against HIV/AIDS; solidarity instead of sympathy is needed.

The WCC study claims that “Christians make ethical choices in accordance with certain principles, which follow from their understanding of the biblical witness and their faith convictions.”^[84] These ethic perspectives differ in various ways amongst the different church denominations, but they are likely to include the following aspects:

- “because all human beings are created and beloved by God, Christians are called to treat every person as of infinite value;
- because Christ died to reconcile to God, Christians are called to work for true reconciliation – which includes justice – among those alienated one from another;
- because we are “members one of another”, being built up by the Spirit into the body, Christians are called to a responsible life within the community.”^[85]

[...]

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^[1] Most of the mainline churches are members of the “German Action Campaign against Aids, Malaria and Tuberculosis”

^[2] Kevin Kelly in Catholic Ethicists on HIV/AIDS prevention, 2000. p. 324

^[3] Jacob in Fachkreis Ethik, 2004

^[4] India’s caste-system divides its population into thousands of social groups, placing the Dalits at the bottom of social hierarchy. Dalits, in common parlance also called untouchables, belong to the “Scheduled Class”.

^[5] Bishop Magagula from the Eastern Diocese of the Evangelical Lutheran Church of Southern Africa during a partnership visit at Kirchenkreis Bremervörde-Zeven in September 2003.

^[6] UNAIDS, (2004), AIDS Epidemic Update

^[7] Weinreich et al., (2003), p.2

^[8] Gray et al. 2001 in Weinreich et al., (2003), p.3

^[9] CD4 are helper cells, a subgroup of the white blood cells. The standard value lies between 600 – 1300 cells/µl of blood. ARV should be given in the AIDS stage, and/or when the CD4 cell count has fallen below 200/µl (Weinreich et al., 2004), p. 79

^[10] ITAC, (2002)

^[11] Faith in Action, (2002)

^[12] UNAIDS defines an AIDS orphan as a child who has lost one or both parents due to AIDS. An AIDS orphan might be HIV-negative or -positive.

^[13] UNAIDS together with the World Health Organization (hereafter, WHO) issues epidemiological reports on an annual basis. The global collection and surveillance of data on HIV/AIDS is a joint undertaking of UNAIDS and WHO in cooperation with the national data collection systems and other organizations. In many countries such as Ethiopia, data collection is not very accurate. All data are estimates and not precise counts of infections. The methodology used has been improved over the years. For some years already, UNAIDS has published data with an average estimate, a low estimate and a high, e.g. 1 500 000 (950 000 – 2 300 000). The data give figures and estimates for HIV prevalence. Prevalence is the number of existing cases at a given point in time related to the population.

^[14] „Adult population“ in the UNAIDS data collections is defined as people between 15 and 49 years.

^[15] The World Factbook (2005), Ethiopia

^[16] ibd.

^[17] The World Bank Group (2005),Ethiopia Data Profile

^[18] Ministry of Health (2004), AIDS in Ethiopia

^[19] Ministry of Health (2002),AIDS in Ethiopia

^[20] ibd.

^[21] Ministry of Health (2004): AIDS in Ethiopia

^[22] Mulonzya, 2003

^[23] Census India (2001)

^[24] The World Bank Group: India at a Glance, (2004)

^[25] ibd.

^[26] Indian Churches (2003)

^[27] The World Bank Group: India at a Glance, (2004)

^[28] Indian Economy Overview

^[29] ibd.

^[30] ibd.

^[31] Philip Kurvilla, (2004): HIV/AIDS: A Handbook for the Church of India

^[32] UNAIDS; UNICEF, WHO (2004): “Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections – India”

^[33] Philip Kuruvilla: HIV/AIDS: A Handbook for the Church in India

^[34] UNAIDS; UNICEF, WHO (2004): “Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections – India”

^[35] Cohen, (2004) in AIDS epidemic update: December 2004, p.8

^[36] Frederiksson, Jenny, (2005), HIV & AIDS in India

^[37] ibd.

^[38] ibd.

^[39] UNAIDS; UNICEF, WHO (2004): “Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections – India”

^[40] Philip Kuruvilla: HIV/AIDS: A Handbook for the Church in India

^[41] Although sex work is legal in some states, associated activities including soliciting and brothel keeping are being penalised. Women often get involved with sex work because of poverty or marital break-up, or they are forced into it.

^[42] Frederiksson, Jenny, (2005), HIV & AIDS in India

[43] Philip Kuruvilla, (2004): HIV/AIDS: A Handbook of the Church of India, p. 44 f

^[44] ibd.

^[45] Frederiksson, Jenny, (2005), HIV & AIDS in India

^[46] UNAIDS (2001): “India: HIV and AIDS-related discrimination, stigmatization and denial”

^[47] The Hindu. front-page, 16 February 2005

^[48] Frederiksson, Jenny, (2005), HIV & AIDS in India

^[49] Parrey (2003)

^[50] Statement by Faith-Based Organizations facilitated at the World Council of Churches for the UN Special General Assembly on HIV/AIDS, June 25 – 27, 2001

^[51] UNICEF (1995): Religious Leaders as Health Communicators, New York

^[52] WCC (2001), p. 5

^[53] I use the common scientific notation with the capital letter of theological literature

^[54] WCC (2001), p. 23

^[55] ibd., p. 23

^[56] M. Kurien (2004), The Threat of HIV/AIDS: Some Theological Considerations in HIV/AIDS: A Challenge to Theological Education

^[57] WCC (2001), p. 24

^[58] ibd., p. 24

^[59] Aurelius Augustin (354-430) is a central figure both within Christianity and in the history of Western thought. His doctrin influences the dogma of the Christian churches till today. Augustine was important to the “baptism” of Greek thought and its entrance into the Christian, and subsequently the European intellectual tradition.

^[60] WCC (2001), p. 25

^[61] A Report on HIV/AIDS from an International Workshop in HIV/AIDS: A Challenge to theological Education, p. 141

^[62] WCC (2001), p. 26

^[63] ibd., p. 26

^[64] ibd., p. 26

^[65] ibd., p. 26

^[66] The Threat of HIV/AIDS: Some Theological Considerations in HIV/AIDS: A Challenge to theological Education, p.6

^[67] Director of Indian Centre of Social Change

^[68] HIV/AIDS: Towards an Ethic of “Just Care”, in HIV/AIDS: A Challenge to theological Education, p. 35

^[69] ibd., p. 27

^[70] Jacob, Beate: „Kann Krankheit eine Frage von individueller Schuld sein?“ in Fachkreis Ethik, 2004, p. 5

^[71] WCC (2001), p. 27

^[72] ibd., p. 27

^[73] ibd., p. 28 f

^[74] ibd., p. 29

^[75] Kuruvilla (2004): HIV/AIDS

^[76] Kuruvilla (2004): HIV/AIDS, p. 140

^[77] ibd., p. 140

^[78] quoted from the “Plan of Action”, formulated at the “Global Consultation in Ecumenical Responses to the Challenge of HIV/AIDS in Africa”, Nairobi, Kenya, 25-28 Nov. 2001in Kuruvilla (2004): HIV/AIDS, p. 140

^[79] adapted from „Facing AIDS in the context of Vulnerability“ – module on Vulnerability, published by WCC 1999 in Kuruvilla (2004): HIV/AIDS, p. 141

^[80] WCC, (2001) p. 77

^[81] ibd., p. 77

^[82] ibd., p. 83

^[83] Luitgard Fleischer, „Warum trifft die Pandemie arme Länder überproportional?“ in: Fachkreis Ethik, 2004, p. 17

^[84] WCC (2001), p. 47

^[85] ibd., p. 47 f