14. Perception and Belief about HIV/AIDS Among the Ulama (Muslim Scholars) in Kano

Zainab S. Kabir

Islam and Hausa culture have been intertwined to the extent that sometimes people mistakenly attribute certain Hausa cultural practices to Islam. According to some scholars, Hausa culture as it is known today is an amalgamation of different cultures that had evolved as a result of interaction and intermarriage between different groups (Berkow, 1973).

Traditionally, the Hausa people teach their children a form of sexual education through parents and Islamiyya (schools where Islamic education is taught). Through such schools, the onset of puberty, menstruation, and other similar issues are taught (Yusuf, 1996). In Hausa society, the means of transmission of HIV/AIDS have been recognized predominantly through homosexual and heterosexual relationships, blood transfusion, and mother to child transmission (Magaji, 1996). Homosexual activities, fornication, and adultery are considered very serious offenses in Islam and their punishment, which is severe, entails death to the adulterer and one hundred lashes to the fornicator. The introduction of Shari’a (Islamic law) in many northern states affirmed this and brought about objection by the Western World on the grounds of human rights (Human Rights Watch).

The scourge of HIV/AIDS has made it one of the leading causes of death all globally, with Africa being the hardest hit. One out of every ten adults in sixteen countries in Africa aged 15 – 49 is affected; while in seven countries one out of every five is infected. West Africa more than anywhere else in the world has the most severe epidemic. It was assessed that about 25.4 million people were HIV positive with about 3.1 million new infections in the year 2004 (UNAIDS/WHO, 2004). In Nigeria, the national prevalence rate surged from 1.9% in 1993 to 5.4% in 2003. At present approximately 3.6 million people are HIV positive, and there is an infection rate of 6%. Although there is enough information on AIDS and the danger it poses, the fact that any discussion of sex within the community is an anathema, makes it impossible to introduce sex education into schools or to conduct a campaign on the use of condom. It is, therefore, a great challenge to the Muslim population in Nigeria, which is estimated to include roughly 60% (UNAIDS, 2004).

Knowledge of public attitudes toward HIV/AIDS and its treatment is a vital force in providing successful preventive and curative services for the disease, especially those that are community-based. The recognition of the HIV/AIDS problem also depends on a careful evaluation of the norms, belief, and customs within the individual’s cultural environment.

People have strong feelings and beliefs about the origin and cause of HIV/AIDS and many of these concepts are founded on religious beliefs and the local cultural systems of the community. In developing and HIV/AIDS education program, the basis of these beliefs must be taken into consideration. The principles regarding HIV/AIDS illness should not only be known, but the purpose of these beliefs should be understood as well. Education that proceeds without this understanding probably holds no benefit. It is also possible that ignorance and stigma prevent the HIV/AIDS victims from seeking appropriate help. Community attitude and beliefs play a role in determining the help-seeking behavior and successful control of HIV/AIDS (Schofield, 1979). Nevertheless, there is little research on the attitudes of Muslim Scholars towards HIV/AIDS victims in northern Nigeria, despite the fact that the perception, belief, and attitudes of the Ulama inevitably have a profound influence on the thinking and behavior of the generality of the local population.

This study was carried out among the Ulama in order to ascertain the perceptions of manifestations, causes, and treatment of HIV/AIDS. The population’s attitude towards the disease in Kano metropolis, Northern Nigeria was also studied.

Materials and Methods

Study Area

Kano Metropolis is located in Kano State, within the Northern part of Nigeria. It is comprised of six local governments, namely: Kano Municipal, Dala, Fagge, Tarauni, Gwale, and Nassarawa. It has a population of 1.7 million (National Population Commission, Nigeria, 2006). The majority of the people are Muslims preoccupied with different types of jobs, e.g. civil service, trading, farming, etc. The area has federal, state, and local government health facilities. These include Aminu Kano Teaching Hospital (AKTH), which is one of the Federal governments designated Anti-retro-viral (ARV) treatment centers for HIV/AIDS. The State Government has four General Hospitals and a specialist hospital.

Each local government has health centers, health clinics, and maternal and child welfare clinics. In addition to these, the study area has several herbal/traditional healers. Suspected HIV/AIDS referrals are sent to the Teaching Hospital. Consent for the study was obtained from the respective local governments. Informed consent was also obtained from respondents prior to commencement of the interviews.

Study Population

The study population consists of the Ulama. Technically, “Ulama” mean scholars, but in this respect, the Ulama are Muslim scholars who live in the community. The Ulama are the teachers and scholars who were among the most learned and knowledgeable members of the society and who had regular contacts with people over a broad area—contacts that could even be reinforced through written messages (Shea, 1983).

They are teachers, preachers, and sometimes leaders. Some of them have professional occupations apart from preaching and teaching. They are looked upon as the experts in religious teaching and interpretation; therefore, their opinion is highly sought and valued in virtually all aspects of life. They hold a high position within the society, because people listen to them and respect them. They are gate keepers and opinion molders of their community. Without their support, it is difficult to get anything done in the community (Siddiqui, 1984).

With the introduction of Shari’a in some of the states in Nigeria the role of the Ulama became even more eminent. Their role in the interpretation, guiding, and application of Shari’a makes them the custodians of religion, culture and value of the community. The crucial place they occupy makes them an important factor in molding ideas and in acceptance or rejection of programs and projects. This is even more the case in regards to HIV/AIDS, which is viewed with suspicion and great trepidation. For acceptance of any resolution on how to prevent and manage HIV/AIDS victims, the Ulama must be convinced of the safety and usefulness of the approach. The aforementioned are the reasons why the Ulama were targeted as a group in this study.

Study Design, Sample Size, and Sampling Method

A cross-sectional descriptive study was used. A total of 400 Ulama were selected using the appropriate statistical formula. (Lwanga & Lemeshow) N = Z2pq/d2, N = minimum sample size, Z = confidence limit, at 95% = 1.96, p = percentage affected (from a previous study) = 0.5 as there was no previous study in the region. q = percentage not affected = 1 – 0.5 = 0.5. A minimum sample size of 384 was obtained, which was rounded to 400 to take care of non-response.

The systematic sampling technique was adopted. A list of all the wards in each of the local governments was obtained. The ward heads in the local governments provided a list of all the Ulama residing in their ward. Using the systematic sampling method, a sample size of sixty-seven respondents was selected from the list of scholars in four local governments each, while six were selected from the two remaining local governments giving a total number of 400 respondents.

Data Collection

A pre-tested questionnaire was administered to respondents by trained graduate students. Data were collected about personal particulars of respondents including their age, marital status, occupation, and educational status. The perceived views of the respondents’ cause of HIV/AIDS were ascertained, and the perceived manifestations of the disease as well as its prevention were also recorded. The last sections of the questionnaire contained questions on the respondents’ preferred treatment for HIV/AIDS and what their attitudes towards victims of the disease were.

Data Analysis

The data were analyzed using percentages and range, as appropriate using the EPI—info 6.0 statistical software package (CDC Atlanta, Georgia, USA). Microsoft Word in Windows 98 was used for tabulations.

Result

There were 400 respondents with 376 (94%) of them being males and 24 (6.0%) being females. Twenty seven percent of them were between the ages of 40-49 years, while majority of the respondents (73%) were between the ages of 30-59 years. Fifteen percent were 60 years and above, while 12.5% were in the category of 20-29 years.

The majority of the respondents (74%) had only an Islamic/Qur’anic education. Those who had Qur’anic/Islamic education with some form of Western education were 27.75%. Only 12% of them had secondary and tertiary level of education while 1.25% had postgraduate education. Virtually all the respondents in this study were married men and women.

The majority is solely Qur’anic teachers by profession, but others in addition engaged as civil service or undertake private enterprises. Most of the women in the study were housewives in addition to being Qur’anic teachers.

*Percentage represents properties of responses obtained.

Sexual intercourse was identified to be the main cause of HIV/AIDS by the respondents. This includes homosexual intercourse with 29.0% and heterosexual intercourse with 28.6%. These were followed by the belief that the disease was the effect of divine wrath or God’s will (18.2%) and the use of unclean instruments (7.4%). Suffering the disease because of possession by evil spirits or due to evil works of an enemy were uncommon responses.

*Percentages represent properties of responses obtained.

The major perceived that the primary manifestation of HIV/AIDS was loss of weight with 32%, followed by diarrhea with 18.4%. The least was mental disorder with 5.3%.

All the respondents agreed that abstinence and faithfulness were keys to the prevention of HIV/AIDS. Those who mentioned condom were 42%, but they were quick to add that though it was an effective way of preventing AIDS, they would not promote its uses because the availability of it would encourage sex outside marriage, particularly among the youth. Those who believed that taking orthodox and traditional medicine could prevent AIDS were 27.5%. The basis of their belief was that there are some herbal preparations that, if taken, could prevent illness such as HIV/AIDS. Sex with young girls had only 0.75% response.

The majority of respondents (48.0%) preferred orthodox medicine in the treatment of HIV/AIDS. Those who favored spiritual healing were 29%, and those who chose treatment with traditional medicines were 21%. Only a few of the respondents (2%) mentioned a preference of other ways, such as ingesting honey, as preferred treatment for the disease.

The majority of the respondents had a positive attitude towards the victims of HIV/AIDS. Over 37% said they would be kind to the victims while 35% said they would be sympathetic to them. Those who would avoid the victims accounted for 15.5% of the respondents while 0.75% would be hostile to them.

Discussion

This study identified perceptions, beliefs and attitudes of the Ulama residing in Kano metropolis in northern Nigeria. The majority of them had a Qur’anic/Islamic education. This shows that the Ulama emphasize pursuit of Qur’anic, Arabic, and general Islamic education more than they pursue a Western type of education.

On the issue of the respondents’ perceived causes of HIV/AIDS, all the respondents mentioned sex outside marriage as being the foremost cause of HIV/AIDS. Sexual intercourse involving heterosexuals and homosexuals was seen as a major cause of HIV/AIDS with a ranking of first and second in Table 2. Similar research in six districts of Tanga region in Tanzania, which is majority Muslim, shows that the respondents had a good knowledge of the causes of HIV/AIDS. This observation also agreed with figures obtained by 1994 data of the United States Center of Disease Control as well as from United Kingdom, Denmark, and Germany (Cockerham, 1998). Those who opined the cause as being a curse from God ranked third (Table 2). They explained that according to religious scriptures when people persist in committing an offense, God will punish them by sending calamities on them. These calamities may include diseases, hurricanes, floods, etc. (Qur’an 54:33-39, Bible: Genesis 19: 24-25). Infection through the blood of an infected person as a cause of HIV/AIDS recorded fewer respondents, but those who mentioned it explain that they knew people who had been infected through blood transfusion. A small percentage declared that unclean and contaminated instruments were the cause of HIV/AIDS. Perceived causes of the disease through possession by evil spirits and the work of an enemy recorded the lowest ranking of response among the respondents. This is not unconnected with the fact that belief in evil spirits or work of an enemy as causes of ill health is forbidden by Islamic teachings.

The respondents’ most common perceived manifestation of HIV/AIDS was loss of weight, which ranked first (Table 3), while diarrhea and persistent cough ranked second and third respectively. Mental disorder had the lowest ranking. This showed that the Ulama had a fairly accurate perception of the clinical manifestations of AIDS, a fact that may not be unconnected with the wide publicity the manifestation of the disease gets in the media as well as from interpersonal discussion.

All the respondents interviewed agreed that abstention and faithfulness were the keys to a successful prevention of HIV/AIDS with the highest-ranking order on each aspect. Some scholars have argued that in a situation where polygamy exists and women sexuality is controlled, faithfulness, as a perceived means of prevention, will fail. According to Kugle, “We need to think more clearly about ‘intimate citizenship,’ how personal, emotional, and sexual dimension of our lives actually have very public and often political consequences” (Kugle, 2003). Some of the respondents mentioned condom as an effective way of avoiding AIDS, ranking as high as 2 on Table 4, but they were quick to add that they would not promote its use because its availability will encourage fornication among the people since condoms are also contraceptive devices. Factors such as the attitude of the Ulama might have accounted for low usage of the device in developing countries, where it was reported that its use accounts for only 3 to 4 percent (Mundigo, 1995). The attitude of the Ulama on condom use appears to run counter to that of the Indonesian Council of Ulama and the Islamic Medical Association of Uganda (IMAU) who passed a religious verdict to make the use of condoms permissible (Nicholas, Kader, & Dankyau, 2004). Sex with young girls ranked low from the respondents. Further explanation showed that young girls were believed to be pure, because they had not had any sexual experience, as such they could not pass the infection. A similar finding was reported by a participant from Mexico in a paper presented at a workshop for service providers in an international conference for “International Women Health Coalition” held in Barbados in March 1992. (IWHC, 1994). Gill Gordon also stated similar reasons for the practice of preference for sex with younger women in his book titled Learning about sexuality, published for “The Population Council, International women Health Coalition” (Sondra & Moore, 1996). A significant number of the respondents believed that taking orthodox and traditional medicine can deter infection. They believe that some herbal preparations or antibiotic pills could prevent the infection in the event of exposure.

A high percentage of respondents (48%) expressed preference for modern medical care in the treatment of AIDS, while traditional medicine had a comparatively lower score. This showed that the respondents had confidence in modern medical care. Some of the respondents believed that traditional and spiritual medicine could a cure the disease. To this effect, centers were set up where patients receive traditional medicine coupled with spiritual healing in the form of verses of the Qur’an. This practice is referred to as dibbul-nabawi (Prophetic medicine).

The majority of respondents in this study viewed the victims of HIV/AIDS with sympathy and kindness. The reasons could be that in Islam the essence of brotherhood and good neighborliness is emphasized. Avoidance and hostility towards AIDS patients were expressed by 16% of the respondents. Their attitude towards of AIDS is negative; they reject and discriminate against people living with AIDS, thereby inflicting pain and stigma on them.

Conclusion

As the Ulama influence the opinion and attitude of many people in the community, and a number of their perceptions and beliefs on HIV/AIDS run counter to proven scientific findings, it is important that an HIV/AIDS control program should take them into account by organizing enlightenment programs aimed at educating and involving Ulama in the prevention and handling of HIV/AIDS victims. Where the perceptions of the Ulama agree with those based on scientific principles, these can be put to good use in mass mobilizing against the disease.

Recommendations

1. There should be an advocacy and managerial capacity building for Islamic religious sector organizations by technical and implementation partners to provide services in HIV/AIDS and to ensure sustainability and efficiency of programs.
2. Development of a strategic action plan and guidelines for advocacy to religious leaders should be in place to ensure and maintain sustainability and efficiency of the program.
3. Support should be rendered to Centers of Excellence (such as the teaching hospitals) where Islamic and modern curricula should be integrated to replicate, share experiences, and integrated health education.
4. Islamic organizations that embark on community sensitization should be encouraged to keep records of their activities for future reference by their successors, so as to maintain and improve on the standards.
5. There should be joint collaborative activities between Islamic religious organization leaders and government and non-governmental organization to maximize the expected outcome of mass mobilization and health education on HIV/AIDS related issues.

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