BY AHMED RAGAA ABDEL-HAMEED RAGAB, MD; PHD PROFESSOR OF REPRODUCTIVE HEALTH, AL-AZHAR UNIVERSITY, CAIRO EGYPT
The HIV epidemic has been spreading steadily that is now, no country in the world is immune. The number of people living with HIV continues to rise every year (Haleprin et al, 2004). With the wide spread of HIV, faith based approach became an important part of HIV and AIDS Prevention. The word of religion has its effect within souls, and Religious Leaders possess a degree and have an effect on peoples’ hearts, thus their role would be significant and effective in HIV and AIDS prevention and care programs.
Religious leaders are the gate keepers for many social and cultural issues. The role of religious leaders in Islam is not restricted to calling for prayer, fasting, almsgiving, pilgrimage and other religious commandments and juristic regulations; but this role extends to include inviting people for various medical, social, cultural and religious fields of life (Omran, 1992). In recognition of the role of religious leaders, bringing them to the field of HIV and AIDS and networking with them and using the faith based approach; the efforts to tackle the problem would be more effective.
HIV and AIDS in the Middle East and North of Africa
Countries in the Middle East and north of Africa region share certain characteristics that shape the sexual and reproductive behaviour of adolescents despite their geographical spread and diverse politics (De Jong et al, 2007). As these populations are predominantly Muslim, Islam has a great influence on sexual and reproductive health behaviour.
The region faces many challenges: strong taboos attached to HIV and AIDS make it harder to measure the scope of the problem and plan accordingly. Extreme stigma not only marginalizes people living with HIV, but also inhibits people from going for testing. People living with HIV are commonly expelled from their homes, are sometimes fired from their jobs and even have trouble in getting medical care for fear of infection by health professionals (Ragab and Mahmod, 2006; Obermyer, 2006; Jenkins and Robalino, 2003)..
In early phases of the epidemic, obedience to Islamic teachings was thought to offer the best protection (Ragab and Mahmoud, 2006, Kandella, 1993). Denial characterized the early phases, especially among the policy makers and the community leaders (Ragab and Mahmoud, 2006, Kandella, 1993) HIV was presented as a disease brought from countries where sexual morals were decadent (Ragab and Mahmoud, 2006, Kandella, 1993).
Estimates of WHO and UNAIDS show that HIV Prevalence is low (0.2%) in the region (UNAIDS, 2006). It has been hypothesized that the low prevalence of HIV in the region is somewhat linked to Islam and its influence on the behaviours that affect transmission (Obermyer, 2006). Gray (2004) says comparative analysis of data from African countries showed that the prevalence of HIV was negatively associated with the percentage of the population that is Muslim. However, Gray’s study affirmed that the link between being Muslim and sexual risk factors is ambiguous and variable.
Currently, all countries of the region compile statistics on reported cases of HIV and AIDS, but case definitions are inconsistent and local capacity of diagnosis and reporting is uneven (Obermyer, 2006). Nearly all countries screen blood donors, but epidemiological surveillance is lacking and monitoring of special risk group is infrequent and at times hampered by local sensitivities (Obermyer, 2006).
The most recent estimates of the number of people living with HIV in the region are about half a million (UNAIDS 2006). However, the reliability of the estimates is questionable, because of the nature of the syndrome and the strong stigma that may hinder many of those who are suspicious of being infected from being tested (Obermyer, 2005, UNFPA, 2004). Furthermore, the prevalence of sexually transmitted infections is relatively high and indicative of unprotected extramarital sex (Heikel, et al 1999). People living with HIV are commonly expelled from their homes or alienated from their families, are sometimes fired from their jobs and even have trouble getting medical care for fear of infection by health professionals.
The region faces tremendous challenges which have potential implications for the spread of HIV: war related forced migration, economic and physical embargo in some places, rapid urbanization and poverty in many countries as well as a population structure in which the majority are young people. In addition there are hundreds of thousands of travellers and workers from high prevalence countries who enter and leave each year. Furthermore, there is evidence of increasing injecting drug use which carries the potential for HIV transmission. In addition, men who have sex with men became significant recently. The issue of blood safety remains of persistent concern in the region, where millions of blood units are donated each year and screening is still far from comprehensive in several countries (Ragab and Mahmod, 2006; Obermyer, 2006; Jenkins and Robalino, 2003).
Further spread of the virus, and especially deaths from the disease, could lead to a drastic decline in productivity, a decrease in the labour force and a reduction in capital investments. The World Bank estimates that HIV and AIDS in the Middle East and North Africa could cause a loss of one-third of the region’s current gross domestic product by 2025.
Harm reduction approach faces a great challenge. While distributing needles is widely accepted, promoting condom use is a problem in the region. There is a strong negative attitude of, particularly, the religious leaders against the programmes that distribute condoms.
It is commonly believed among the policy makers and the population at large that the region’s conservative socio-cultural norms are resistant to change. However, a critical observer of the region would come to a conclusion that there are rapid socio-cultural changes. These changes have led to a decrease of the moderate population. There is an observed increase in both extremes: the conservatives and the more liberals. Both groups, “the conservatives and the liberals” are influencing negatively the efforts to tackle the problem: While the first have strongly stigmatised people living with HIV, the second is contributing to the increased number of people living with HIV.
What Muslim Religious Leaders Can Do?
In order to answer this question, it is necessary to understand the basic Islamic Principles.
Islam is a code of life; consequently Islamic legislation is very comprehensive. They do not deal exclusively with questions of faith and worship. They also regulate moral behaviour, social interaction, husband wife relationships -including sexuality, family formation, family planning, and abortion (Omran, 1992, Musallam, 1978).
Contrary to the image of Muslims and Islam, Islam at its ideal level is a religion of peace. One of the fundamental characteristics of Islamic law is the principle of ‘liberty’ or permissibility ‘ibaha’, that is ‘everything is lawful unless explicitly designated otherwise’. The other two principles: It is a religion of ease (Yusr), not hardship (Usr) and a religion of moderation (Omran, 1992, Musallam, 1978).
In Islam there is no hierarchically organized clergy, nor a central authority that dispenses a single interpretation of the faith. This decentralization means that the various schools of law and religious sects follow codes that are sometimes dissimilar (Omran, 1992, Musallam, 1978). Consequently, it is observed that there are many differences among scholars which foster the confusion regarding Islam among its followers and others.
At its ideal level, Islamic Shari’ah regulates all types of human behaviour. It regulates relations between husband and wife, parents and children, among neighbours, with individuals and within the society. Being the last revealed religion, the provisions of Islamic Shari’ah had to apply at all times and places as it was inconceivable that perfecting Shari’ah would lack provisions to cover all developments that might occur over the years (Omran, 1992, Musallam, 1978)..
The Shari’ah is a comprehensive system of rules and regulations that practically covers all aspects of individual or collective human affairs, with the ultimate objective of assuring human welfare in this world and in the hereafter.
The primary sources of Shari’ah are:
1) The Qur’an, the very word of Allâh
2) The authentic tradition and sayings of the Prophet
3) The unanimous opinion of Islamic scholars, and
4) Analogy, the intelligent reasoning by which to rule on events that the Qur’an and tradition did not mention, by matching against similar or equivalent events already ruled on.
There are several secondary sources of Shar’iah. Shari’ah is therefore not fixed except in worship rituals, codes of morality and only a few legislations, leaving latitude to adapt to new situations in different times and places, and accommodating even differing honest opinions as long as they do not conflict with the letter or the spirit of the Qur’an and Tradition.
The development of the of jurisprudence (Fiqh) resulted in the establishment of certain guiding principles to help drive rulings which are important for HIV and AIDS programmes, such as “necessities overrule prohibitions” – “harm should be removed” – “the choice of the lesser of two harms” – “Public interest takes priority over enjoying benefits” – and the so called the rule of rules: “Wherever welfare goes, there goes the statute of Allah”. All these principles would be the basis of the faith based approach in Muslim countries (Omran, 1992, Musallam, 1978).
The objectives of Shari’ah are the preservation and protection of, among others:
– Self (life, health, hygiene, nourishment, prevention and treatment, protection, etc).
– Mind (prohibition of alcohol and drugs, freedom of thought and pursuit of knowledge, etc.) (Omran, 1992, Musallam, 1978).
Logically, emphasizing these objectives helps much in responding to HIV and AIDS. Human life is highly valued in Islam; it is considered a gift from Allah. Muslims believe that bodies are held in trust from Allah that must be returned one day and they will be asked, among others, how looked after it. Therefore they should avoid any act which will harm their health.
Sex Education in Islam
Islam appreciates the sexual desires that humans have. Therefore, it encourages that these desires be fulfilled. Like other revealed religions, Islam encourages marriage, so that through marriage, sexual desire can be fulfilled. The Prophet (PBUH) always encouraged discussions on matters which help protect sexual health. Muslim men and women never felt shy to ask the prophet (PBUH) about intimate sexual matters. The Holy Qur’an has discussed reproduction and sexual health in several verses (Omran, 1992, Musallam, 1978).
Sex education in Islam was provided side by side with other teachings. Followers of Islam never felt shy to ask the Prophet or His wife ‘Aisha’ questions related to their intimate sexual matters. Clear instruction of the Prophet (PBUH) was given regarding sexual rights for both men and women. Ensuring mutual satisfaction was mentioned clearly by the Prophet (PBUH) and the rights for women to achieve their orgasms were strongly emphasized. Islam forbids all acts which were believed to harm the sexual health like sex out of wedlock, sex with a menstruating woman, homosexuality, sex with animals and anal intercourse. It is safe to argue that, while Islamic sex education not only put a high value on abstinence and be faithful approaches, it is also a comprehensive type conditioned by the marital status, sexual intercourse would be practiced only within marital relations.
It is not abstinence only; rather it is a comprehensive one
At the time of the Prophet, a comprehensive package of sex education was given side by side with other teachings of Islam. The followers (men and women) used to ask about their sexual problems, and the Prophet used to clarify what was obscure. In addition, women used to ask ‘Aisha’, the Prophet’s wife, about some aspects of reproductive health. Different sex education messages are mentioned in the Quran and the Hadith (Sayings of the prophet) among them are:
– Sexual Positions
– Withdrawal (ejaculation outside vagina)
– The Importance of the Foreplay
– Sex during Menstruation
– Anal Intercourse and men who have sex with men.
The Rights and Duties in Sexual Relations in Islam
All scholars indicate that the right to sexual enjoyment is one of the wife’s rights (Omran, 1992). They never denied her right to sexual fulfillment. Sexual fulfillment for women was understood to depend on the completed act of intercourse, something which withdrawal was not (Mussallam, 1978). Accordingly, some scholars disallowed withdrawal without the consent of the wife as they believe that it would interfere with her right for enjoyment. However, these rights are balanced by women’s duties.
Islam and Sex outside Marriage
Islam forbids all types of sex outside marriage: premarital and extramarital. Islam advocates a number of specific measures to reduce the temptations towards it. First, the Prophet advised all followers (especially the youth) to get married if they could, so that their natural desires have a legitimate fulfillment. Sex outside marriage is considered in Shari’a not only as a sin but also as a crime which is punishable under law.
Islam and Sexual Health
The teaching of Islam forbids all that was believed to be damaging sexual health: anal intercourse, sex with animals, sex with menstruating women and homosexuality. Although some of these practices are debatable and there are question marks regarding their damaging effects, however, what is important is the general principle, that Islam is against all that would be proven to have bad influence on sexual and reproductive health.
Islam and People Living with HIV
Contrary to a recent impression about Islam and the Muslim population, Islam is a religion that is full of compassion, love and mercy. The Prophet Muhammed (PBUH) reminded his followers that “You will not enter the paradise until you believe, and you will not believe until you love one another”. In another statement by him, it has been said: “Allah shows compassion only to those who are compassionate”. Love and compassion are the qualities of a good Muslim and are needed by people living with HIV.. These facts would be of much help for faith based programmes and give a good basis for calling for support for people living with HIV.
Most of the programmes that involve religious leaders assume that, religious leaders need only information and they are going to be involved. However, working in many programmes, I came to a conclusion that providing information does not ensure changing the attitude and changing the attitude does not ensure changing the behaviour. The cultural and social environment where such programmes are carried out greatly influence the outcome of such programmes.
Applying this argument to the current HIV prevention and care programmes among Muslims, one can witness a division among the religious leaders. Some believe that HIV and AIDS is a punishment by Allah for sinners and drug addicts. Consequently they think that people should be treated according to the route of transmission, those who contracted the virus from out of marriage sexual activities should not be treated with mercy. This contrary to the official religious leader’s authority, that there should not be any form of discrimination based on the route of transmission. Each group supports its argument with texts from the Quran and Prophet (peace be upon him) traditions.
Due to certain political factors (armed conflicts in many countries, the sense of western conspiracy against Muslim population, etc) and economic factors (increasing unemployment and poverty, wide spread corruption), there is an increase in the number of conservatives. With the increasing conservatism in most of the countries, people living with HIV would face problems in the near future, unless there are drastic actions that bring back moderation to the Muslim countries. Moderation is a characteristic of Islam at its ideal level (Omran, 1992).
The Middle East and north of Africa have all the potentials for rapid spread of HIV. Within the context of the challenges that the Middle East and North of Africa face, it is safe to conclude that a faith based approach has all the potential for success in the Muslim countries, if it is presented and handled appropriately and uses the sources of Shari’ah at its ideal level. Islam forbids all acts which are believed to be harmful to sexual health, like sex out of wedlock, sex during menstruation, homosexuality, sex with animals and anal intercourse. Applying these teachings will help in keeping sexual health and prevent sexually transmitted diseases including HIV.
Critical examination of Islamic teaching shows that there are elements for a comprehensive package of sex education. However, in order to overcome the expected resistance, abstinence should be at the center of the package.
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