1. Introduction

Persons living with HIV/AIDS (PLWHA) when they have come to know of their HIV sero-positivity are normally faced with the problem of disclosure, that is, whom to share the information with, how to go about it and when to do it. Persons living with HIV therefore find themselves in a dilemma when confronted with the phenomenon of HIV status disclosure in the light of the benefits and problems that come with it. According to[1] disclosure of one’s HIV sero-positivity status may provide the opportunity of receiving social support in order to cope with the disease. Disclosure also has the potential of reducing HIV infections, particularly, of the sexual partner[2], by raising awareness and decreasing risky behaviours[3]. It may also lead to provision of appropriate medical care for the PLWHA. On the other hand, not disclosing one’s HIV sero-positivity can be a way of protecting oneself against stigmatization and discrimination[4], as the disclosure has the potential of leading to physical violence, fear, worry, shame, rejection or abandonment[5]. Non disclosure of one’s HIV positive status also has the potential of interfering with accessing and adhering to appropriate and critical medical treatment[3].

[6] and[7] have noted that most studies of HIV self disclosure in Sub Saharan Africa have focused primarily on disclosure to sexual partners and spouses especially among women. Few studies examined disclosure to others in the social network[8] including the religious communities[7] and such studies including[9],[10],[11] and[12] are mainly from the Eastern and Southern Africa.[13], however, have stressed that religion is among the many factors which influences HIV positive status disclosure beyond the caregiver-patient dyad, though findings have been somewhat inconsistent.

The virtual lack of research in the area of HIV status disclosure in the religious setting in West Africa and for that matter Ghana necessitated this study. The main concern of the study was therefore to assess HIV-self disclosure in religious settings using hypothetical questions for religious adherents of Orthodox, Pentecostal/Charismatic, African Traditional Religion, African Independent Churches and Islam in two areas, namely, Ashaiman Municipality, an urban slums, and Tema Metropolis, an industrial hub of Ghana. Specifically, the study sought to probe into the nature of religious adherents’ HIV status disclosure to the religious community if they were to become infected; identify the reasons for disclosure or otherwise of HIV status in the diverse religious settings.

2. Methodology

The study was situated in the two communities of Ashaiman Municipality, an urban sprawl, and Tema Metropolis, an industrial hub and the main harbour city of Ghana. The two study areas lie along the eastern coast of Ghana, about 30 kilometres away from Accra, the capital city of Ghana, with Ashaiman Municipality lying a little inland. While Tema Metropolis is planned with all the modern facilities that one can think of, Ashaiman Municipality is an unplanned community developed into urban sprawl with all its associated problems. The two communities have numerous religious groups which co-exist peacefully, with the Pentecostals constituting the largest group followed by the Protestants. The data for this research were secured from a survey carried out by the researcher in the two study areas in 2010.The main research instrument used was self-administered questionnaire. The structured questionnaire apart from capturing the demographic characteristics of the respondents also had questions which measured the following:

i. HIV status Disclosure to the religious Community: This was captured using an index made up of two questions:

a. If you were HIV positive, would you tell your pastor? Yes/No

b. If you were HIV positive, would you want your congregation to know? Yes/No

An affirmative answer (that is, Yes) to any of the questions meant that the respondent was in total agreement with the index being measured. The disclosure of HIV/AIDS status to the religious community in the two study areas was examined in the light of an index which was constructed as well as the individual questions that make up the index with respect to religious affiliation, gender and level of education of religious adherents.

ii. Reasons for Disclosure and non Disclosure of HIV status: These were solicited from respondents using this question:

If you were HIV positive, would you tell your religious leader? If Yes, give reasons, If No, give reasons.

The study population for the research was made up of Religious adherents of the following religious traditions found in the study areas: Orthodox Churches (Presbyterian, Methodist, Catholic and Anglican Churches), Pentecostal/Charismatic Churches (Pentecost, Assemblies of God, Apostolic Churches), African Independent Churches (Kristo Asafo, African Faith Tabernacle and Church of the Lord), Islam (Ahmadiyya and the Sunni) and African Traditional religion (Worshippers who worship the Supreme Being through the lesser gods).

A multi-staged sampling method comprising purposive and convenience sampling methods as well as stratification procedures was employed to sample 100 religious adherents from Ashaiman Municipality and 150 religious adherents from Tema Metropolis. The sample sizes chosen for the respective areas as well as the various religious adherents were in proportion to their populations according to the 2000 population census of Ghana. The data for the research were analyzed using the SPSS package. The data thereof were presented in the form of tables and bar charts.

3. Results and Discussions

3.1. Sample Description

The number of religious adherents selected in the study for the Tema Metropolis was 150 while that of Ashaiman Municipality was 100. In terms of gender, 52 percent of religious adherents from Tema Metropolis were males while in Ashaiman Municipality they constituted 46 percent. The age distribution shows that 70 percent of the respondents from the Tema Metropolis were within the age group of 18 to 35 years, 22 percent were within the age group of 36 to 49 while those who were aged 50 years and above made up 8 percent. In the case of Ashaiman Municipality the 18 to 35 years were made up of 71 percent of the respondents, the 36 to 49 age group constituted 19 percent while those were aged 50 and above made up 10 percent of the respondents. What was clear in both study areas were that the respondents were chosen to reflect the youthful nature of the population which is characteristic of urban populations. The small percentage of respondents reflecting 50 years and above also reflected what pertains at the national level. The educational background of respondents showed that in Tema Metropolis 9 percent did not have any formal education, 13 percent had primary education while 39 percent each constituted those who had secondary and tertiary education. In the case of Ashaiman Municipality those who did not have formal education formed 12 percent, 18 percent were those who had primary education, 46 percent were those who had secondary education while those with tertiary education constituted 24 percent. The employment status of respondents showed that in Tema Metropolis 28 percent had formal employment, 29 percent were self-employed, 7 percent were unemployed, 34 percent were students and 2 percent were retired. In the case of Ashaiman Municipality 19 percent of respondents were formally employed, 40 percent were self-employed, 8 percent were unemployed, 31 percent were students and those on retirement constituted 2 percent.

With respect to marital status, the study showed that 57 percent of respondents from Tema Metropolis were not married, 3 percent of the respondents were cohabitating, while 37 percent were in marriage relationships with only 3 percent in other relationships (divorced or widowed). In the case of Ashaiman Municipality, 47 percent of the respondents were not married, 14 percent were cohabitating, and 37 percent were married while 2 percent were in other relationships, either divorced or widowed. Apart from the religious affiliations of respondents which have been dealt with in the methodology, 89 percent of respondents attended religious activity at least once a week in his or her religious organization in Tema Metropolis. In the case of Ashaiman Municipality 96 percent of respondents attended a religious activity at least once a week.

3.2. Willingness to Disclose HIV Status and Religious Affiliation

Disclosure rates are often seen as a proxy for the amount of real or perceived stigma in a society[10]. Disclose rates have also been noted to be generally low in Sub-Saharan Africa, partly due to high levels of stigmatization[14]. Disclosure within the Church, and for that matter in the religious community, is seen as a way of reducing stigma. This assertion was affirmed by[12] when it stated that if one can ‘break the silence’ by disclosing, and be accepted by one’s fellow congregants, this may disrupt the perception that ‘other’ people get HIV, and that it is morally reprehensible. Several factors including education, religion, gender and relationship to the one to whom the disclosure is made have also been shown to influence disclosure of positive sero-status beyond caregiver-patient dyad[13].

Table 1 shows the performance of the index used in the two study areas. From the table, religious adherents in Tema Metropolis were more likely to disclose their HIV status to the religious community than those in Ashaiman Municipality. This is because 67.7 percent of religious adherents in Tema Metropolis were willing to disclose to the religious community as against 53 percent of religious adherents in Ashaiman Municipality.

Table 1. Willingness to Disclose HIV Status to Religious Community by Religious Affiliation

What is striking was the fact that no respondent of African Traditional Religion from Tema Metropolis was willing to disclose his or her HIV status to his/her religious community. In Ashaiman Municipality, however, religious adherents less willing to disclose their HIV status to religious community were the Pentecostal/Charismatic Churches (45.9%). Their unwillingness to disclose might have been borne out of the conviction that they would not receive the sympathy and care of their religious communities.

Table 1 further revealed that religious adherents most willing to disclose their HIV status to religious communities were Pentecostals in Tema Metropolis (83%) (X²=25.8; P<0.005) and African Independent Churches in the Ashaiman Municipality (80%) (X²=3.713; P>0.005). In a similar study in Tanzania, adherents of Pentecostal Churches were also found to be more willing to disclose to the religious community than the Lutherans. The reason given for this was that Pentecostals have a more emotive worship type, with the expectation of disclosure of sins and pietistic understanding of sin and forgiveness[9]. This reason could be applicable to Pentecostal/ Charismatic adherents in this study. Encouraging HIV status disclosure in the religious setting would no doubt help in the fight against the pandemic as it facilitates the initiation of and adherence to ARV treatment.

A closer look at Figure 1 also showed that religious adherents were more willing to disclose their HIV status to their religious leaders rather than to their congregations in both study areas. For instance, in Tema Metropolis 66 percent of religious adherents were more likely to disclose to their religious leaders as against 33.3 percent of adherents ready to disclose to their congregations. In Tema Metropolis also Pentecostals (83.3%) (X²=24.878; P<005) were more willing to disclose their HIV status to their religious leaders than in the case of the other adherents. In the case of Ashaiman Municipality, adherents of AIC (80%) (X²=3.906; P>0.005) were more willing to disclose than the other adherents. In almost all the denominations adherents were more willing to disclose to religious leaders than to their congregations. For instance in Tema Metropolis, 58.2 percent of adherents of Orthodox Churches were willing to disclose to religious leaders as against 30.9 percent to the congregations.

The low levels of disclosure of HIV status to congregations compared to the religious leaders might be due to fear of stigmatization, abandonment and blame on the part of congregational members. These findings buttress the importance of enhancing and fostering spiritual relationships with God on the part of PLWHA as a way of providing support to them. They also generally support the work done among Anglican Churches in Southern African where it was established that disclosure within the Church community was less common than disclosure to family and friends. In that study only 20 percent of PLWHA involved had disclosed to the religious community[12]. Even in Tanzania in the work done by[10], less than 2 percent was willing to disclose to the religious community.

3.3. Respondents Gender and Educational Background and Willingness to Disclose

The HIV status disclosure was also examined using the index and individual questions composing it in the light of the gender and educational background of religious adherents.

Figure 1. Disclosure of HIV Status to Religious Leaders and Congregations

Figure 2. Hiv Status Disclosure to Religious Community by Gender Using Index

In terms of gender, female adherents in both areas were more willing to disclose their HIV status to the religious community than their male counterpart (Figure 2). For example, in Ashaiman Municipality, 57 percent of female adherents were willing to disclose to the religious community as against 47.8 percent of their male counterpart (X²= 0.915; P > 0.005). This finding contradicts the one made by[17] that women who are living with the virus are less likely to talk to their religious leaders about their problems. It also contradicts the findings of[18] in Kumasi, Ghana, that males were more likely to be in favour of disclosure of HIV positive status than females. A further examination of Figure 2 shows that it was only in Ashaiman Municipality that more than 50 percent of male adherents were unwilling to disclose their status to the religious community.

When examined from the perspectives of the individual questions as shown in the Table 2, both male and female adherents in the study areas felt more comfortable in disclosing their HIV status to their religious leaders than to their whole congregations.

This could be due to the following reasons:

● Firstly, that religious adherents did not trust their congregational members as far as keeping the information about their HIV status divulged to them as secretive/confidential,

● Secondly, religious adherents might doubt whether they would receive the needed care and support from the congregation, and

● Lastly, religious adherents might also entertain the fear that the congregation would end up blaming them of their situation instead of helping them.

Table 2 further shows that female adherents in the two study areas were more likely to disclose their HIV status to the religious leader and the whole congregation than their male counterparts.

Examined from the perspective of the level of education of adherents, there appeared to be no relationship between HIV status disclosure and the level of education in both study areas as shown in the Table 3. However, there was the general tendency for adherents with higher level of education to disclose to the religious community than those with lower level of education in both Tema Metropolis (X² =2.956; P>0.005) and Ashaiman Municipality (X² = 0.891; P>0.005).

This findings support an earlier work in French Antilles and French Guiana where it was established that less educated people disclose less often to both steady partners and their social network[19]. The possibility that adherents with higher level of education were more likely to disclose their status might be due to the fact that they knew and appreciated the importance of disclosing one’s HIV/AIDS status.

An examination of the individual questions and the level of education in two areas ( in Table 4) show that while in Tema Metropolis 33 percent of adherents without education were willing to disclose their status to their religious leaders, 41.7 percent of their counterpart in Ashaiman were willing to do so. Furthermore, while in Tema Metropolis no adherents without education was willing to disclose to the whole congregation, in Ashaiman Municipality as many as 16 percent were willing to disclose to the whole congregation. At all levels of education, religious adherents in Tema Metropolis were more likely to disclose to their religious leaders than their counterpart in Ashaiman Metropolis except those without education.

Table 2. Hiv Status Disclosure to Religious Community by Gender Using Individual Questions

Table 3. Hiv Status Disclosure to Religious Community by Level of Education Using Index

Table 4. Hiv Status Disclosure of Respondents by Level of Education Using Individual Questions

3.4. Reasons for HIV Status Disclosure and Non Disclosure

In the main questionnaire questions were asked to solicit reasons for why respondents will or will not disclose their HIV status in a religious setting. The study realized three main reasons why religious adherents were ready to disclose their status. These were a) the need to be prayed for so that they could be healed b) to receive care and support and c) for counseling as shown in figure 3.

Figure 3. Reasons for Disclosure Of Hiv Status to the Religious Community in Tema Metropolis and Ashaiman Municipality

Figure 4. Reasons for Non-Disclosure of Hiv Status to the Religious Community in Tema Metropolis and Ashaiman Municipality

From the bar chart about 68 percent of religious adherents from the Tema Metropolis were willing to disclose their HIV status to be prayed for mainly by the religious leader in order to be healed as against 63 percent of respondents from Ashaiman Municipality. The idea of PLWHA disclosing their status to their pastors with the hope that they are prayed for is supported by the work of[15] in Kinshasa, Democratic Republic of Congo, where women were ready to disclose their status to their pastors they believed have got the power to influence the course of their illness. With respect to care and support, 85 percent of religious adherents from Tema Metropolis were willing to disclose their HIV status for this reason compared to 91 percent of religious adherents from Ashaiman Municipality. The desire of many religious adherents from both study areas to disclose their status for this reason might be due to the fact that PLWHA always need to be supported in the form of food and money in order to buy the daily medications that they needed always. This finding appears to be supported by[16] in their study in South Africa where the majority of the PLWHA reported receiving more support of all types after disclosing their HIV status.

With respect to the desire to receive counseling, almost the same percentages of adherents in the two study areas (79 percent from Tema Metropolis and 80 percent from Ashaiman Municipality) were ready to do this. In the case of the findings from the Anglican Churches in Southern Africa only 13.8 percent of PLWHA felt loved and supported after their disclosure[12]. The high percentage of adherents in this study who were willing to disclose their status for the above reasons discussed was quite encouraging since most religious organizations could conveniently provide for PLWHA in order to increase their willingness to disclose.

On the other hand the fear of being gossiped about constituted the major reason for non-disclosure in the two study areas as shown in figure 4.

The questions concerning the reasons were individually answered.

In Tema Metropolis, 91 percent of the adherents gave this reason for not willing to disclose their status if they became infected, compared to 94 percent in Ashaiman. The next major reason why adherents in the two study areas might not be willing to disclose their status was fear of isolation, that is, social isolation which might involve the lost of social networks (friends, family members). This finding is supported by the works of[8] in Uganda in which the most common reason for non disclosure was fear of abandonment, though this was mostly associated with disclosure to spouse/partner and friends. In the present study, the next reason for not disclosing HIV status was fear of blame, that is, where religious members would accuse them of having lived contrary to the word of God. These fears were given credence in the study done among adherents of Anglican Churches in the Southern Africa. Of those who disclosed their status to the church, 19.3 percent reported having often or sometimes lost friends within the religious organization, and 25.4 percent felt of sometimes or often gossiped about[12].

4. Conclusions

In general the willingness to disclose HIV status among adherents in the two areas was above average. In both areas, adherents were more willing to disclose their HIV status to their religious leaders than to their congregations. Female adherents were more willing to disclose their status than their male counterparts. Adherents with higher levels of education were also more willing to disclose their status than those with lower levels of education. This means that religious leaders need to be equipped with HIV counseling skills so that they can be of help to PLWHA who come to them. With respect to reasons for disclosure, majority cited care and support and the need for counseling as reasons why they would disclose their status. For those who said they would not disclose HIV status, they cited fear of being gossiped about, isolated and blamed as their reasons. This implies that religious authorities need to educate their members so that their places of worship will become havens where PLWHA can run to for shelter.