Is HIV prevalence lower among Muslims?

obmar · Site Admin Joined: 14 Apr 2006 Posts: 5697

HIV and Islam:
Is HIV prevalence lower among Muslims?
Social Science & Medicine
Volume 58, Issue 9 , May 2004, Pages 1751-1756
Peter B. Gray
Department of Anthropology, Peabody Museum, Harvard University, 11
Divinity Avenue, Cambridge, MA 02138, USA
Available online 8 August 2003.
Abstract
Religious constraints on sexuality may have consequences for the
transmission of sexually transmitted diseases. Recognising that several
Islamic tenets may have the effect, if followed, of reducing the sexual
transmission of HIV, this paper tests the hypothesis that Muslims have
lower HIV prevalence than non-Muslims. Among 38 sub-Saharan African
countries, the percentage of Muslims within countries negatively
predicted HIV prevalence. A survey of published journal articles
containing data on HIV prevalence and religious affiliation showed that
six of seven such studies indicated a negative relationship between HIV
prevalence and being Muslim. Additional studies on the relationship of
risk factors to HIV prevalence gave mixed evidence with respect to
following Islamic sexual codes (e.g., vs. extramarital affairs) and other
factors, but that benefits arising from circumcision may help account for
lower HIV prevalence among Muslims.
Author Keywords: Author Keywords: HIV; AIDS; Islam; Religion
Article Outline
Introduction
Methods
Results
Discussion
Conclusions
Acknowledgements
References
Introduction
Behaving in accordance with religious tenets may have impacts on health
and disease transmission (Ellison & Levin, 1998; Reynolds & Tanner,
1995). In the context of sexually transmitted diseases (STDs), religiosity
and religious affiliation may be negatively related to STDs because of the
common constraints religions place on sexuality ( Seidman, Mosher, &
Aral, 1992). Religious practices such as circumcision can also affect
transmission rates of STDs. If religious factors associated with HIV––
which is largely transmitted sexually––can be identified, then this
endeavour can be important in helping to understand and predict the
course of the raging HIV epidemic ( Gayle & Hill, 2001; Piot, Bartos, Ghys,
Walker, & Schwartlander, 2001).
Following this logic, this paper examines the relationship between HIV
and Islam. That is, it tests the hypothesis that Islamic religious affiliation
negatively associates with HIV seropositivity. Though this hypothesis has
been proposed before (Lenton, 1997; Ridanovic, 1997), no one, to my
knowledge, has tested it.
For several reasons, adherence to Islamic tenets may confer protective
benefits against the sexual transmission of HIV. While Islamic marital
codes permit men to marry as many as four wives and divorce relatively
easily, potentially increasing the number of lifetime sexual partners––a
known risk factor for acquiring HIV (Stanberrry & Bernstein, 2000;
Wasserheit, Aral, Holmes, & Hitchcock, 1991), prohibitions against sex
outside of marriage may outweigh these risks. If followed, codes against
sex outside marriage for both males and females could reduce premarital
and extramarital sex as well as reduce sexual activity with commercial
sex workers. Prohibitions against homosexual sex could reduce the risks
of, for example, unprotected anal sex.
Islam also prohibits the consumption of alcohol. By increasing risky
sexual behaviour, including reduced use of condoms (Bastani et al., 1996;
Wilson, Lavelle, Mwoboto, & Armstrong, 1992), alcohol consumption may
favour higher rates of sexually transmitted HIV. Islamic attention to
ritual washing could increase penile hygiene, lessening the risk of STD
transmission (see Lerman & Liao, 2001). Lastly, circumcision has been
identified as a practice apparently decreasing HIV transmission ( Bailey,
Plummer, & Moses, 2001; Weiss, Quigley, & Hayes, 2000). Because all
Muslims should be circumcised, this practice may also reduce the
acquisition of HIV. For these reasons, we may expect Islamic religious
affiliation to be negatively associated with HIV. If adherence to tenets
constraining sexuality distinguishes Muslims from members of other
religious groups, or Islamic practices systematically differ from those of
other religions (e.g., circumcision), then we may also find that there is a
stronger, inverse relationship between HIV and Islam compared with HIV
and other religions.
Methods
Two methods of data collection were utilised. First, a multivariate
analysis was conducted which used information obtained from several
large on-line demographic and AIDS databases. All 38 sub-Saharan
African countries with a minimum of 1 million inhabitants were included
in this analysis. Initially, countries from North Africa, Asia, and the
Pacific were also included in this endeavour, but sub-Saharan Africa
emerged as the only region for which sufficient national variation in HIV
prevalence and percentage Muslims seemed to enable meaningful
multivariate comparisons. Attempts to examine regional variation within
sub-Saharan Africa (e.g., west, central, east, and southern African
countries) were also made, but sample sizes were too small to allow
meaningful quantitative conclusions to be drawn.
Five independent (percentage Muslims, population density, percentage
urban population, annual per capita purchasing power, and year of first
recorded AIDS case) and one dependent (HIV prevalence) variable were
obtained as follows for this multivariate analysis. The percentage Muslims
was obtained from the 2000 World Almanac. Population density, percent
urban population and the annual per capita purchasing power were taken
from a 2002 on-line demographic database (www.prb.org). The annual
per capita purchasing power standardises the average income relative to
amounts in $US of goods that could be purchased with it. The year of
first recorded AIDS case reports the earliest year in which an AIDS case
was noted in the UNAIDS database at:
www.unaids.org.hivaidsinfo/statistics
To obtain data on HIV prevalence, the on-line UN database
(www.unaids.org/epidemic update/report/estimates.pdf) was used. All
comparisons involved the percent of HIV positive adults aged 15–49 and
were estimates of HIV prevalence as of the end of 1999. All of these
variables utilised on-line data obtained on 19 May, 2002. The data used
in multivariate analyses were obtained from different sources and by
different methods (i.e., Schwartlander et al., 1999 for HIV prevalence),
and almost certainly vary with respect to accuracy. Nonetheless, these
data represent the best, most recent national data available for
examining the variables considered in multivariate analyses.
The second method of data collection reviewed the published literature
for journal articles linking HIV, risk factors for HIV, and Islam. Standard
on-line searches (e.g., MEDLINE under key words including "HIV and
Islam", "HIV and religion", and "HIV and risk factors") helped identify
studies that showed either (a) relationships between Islam and HIV or (b)
relationships between Islam and risk factors (e.g., extramarital affairs,
alcohol consumption) for HIV. This second method helps specify the
immediate factors by which HIV prevalence might be lower among
Muslims. The literature review was last updated on 21 May, 2002.
Results
The relationship between national HIV prevalence and percentage
Muslims within sub-Saharan African countries is shown in Fig. 1. Across
sub-Saharan Africa, the multivariate regression model was significant
(F=10.60, df=24, p<0.00005) and accounted for a high proportion of the
variance in national HIV prevalence rates (R2=0.69). Of the five predictor
variables, only percentage Muslims ( =-0.516, p=0.0005) and annual per
capita purchasing power ( =0.636, p=0.0002) were significant
(population density: =-0.068, p=0.584; percentage urban population:
=-0.258, p=0.084; year of first recorded AIDS case: =0.244, p=0.059).
(4K)
Fig. 1. HIV prevalence vs. percentage Muslims among sub-Saharan African
countries.
Table 1 summarises the results of studies that allow links between
Islamic religious affiliation and HIV to be made. Six of seven studies
observed a negative relationship between HIV prevalence and Islam. The
one study which observed a positive relationship utilised a different
method than the other studies––it compared HIV prevalence and
percentage religious affiliation among political units (wards) rather than
individuals' religious affiliation with HIV status. Of the two studies on
East African truck drivers (who constitute a high-risk population), one
observed that changes in HIV status were non-significantly lower
compared with Christians, and significantly lower than members of other
religious groups. The second study of truck drivers found that Muslims
and Protestants both had lower HIV rates than truck drivers of other
religious groups. Of the four other studies finding negative relationships
between HIV and Islam, some of these controlled for factors (e.g.,
circumcision (Gray et al., 2000) and lifetime number of sex partners (e.g.,
Malamba et al., 1994) that themselves can be construed as correlates of
Islamic affiliation.
Table 1 Studies linking Islam and HIV
(30K)
Table 2 summarises the studies that contain links between Islam and
factors thought to increase the risk of sexually acquiring HIV. These
findings can be combined with intervening factors (e.g., circumcision)
reported in Table 1 to provide a more extensive set of links between risk
factors and Islam. Two (out of two with data) of these studies found lower
rates of alcohol consumption among Muslims, and one (out of one) study
summarised in Table 1 found a similar result. Thus, 3/3 studies for
which data exist observed negative relationships between Muslims and
alcohol consumption.
Table 2. Studies linking Islam and risk factors for HIV
(18K)
With respect to sexual relationships, 2/2 studies observed higher degrees
of polygyny among Muslims, a possible contributor to more lifetime
sexual partners (a risk factor for HIV). One study found that Muslim men,
but not women, had less extramarital sex; another study that Muslims
did not report less casual sex the previous year; and one study that
Muslims were less likely to have extramarital partners the previous year.
Of the studies in Table 1, one discovered that Muslims were less likely to
have had sex with a commercial sex worker. Taken together, these data
suggest a mixed picture with respect to Muslims having fewer lifetime
sexual partners.
To the degree that circumcision confers protective benefits, Muslims have
apparently experienced these. Four studies (out of four for which data
exist) suggest that Muslims were more likely to have been circumcised
than other members in the study populations. Two other potential risk
factors appeared once: Islam's rules for ritual washing may decrease HIV
transmission, but inferences that it does not allow condom use could
increase sexual HIV transmission.
Discussion
In a sample of sub-Saharan African countries, the percentage of Muslims
within countries negatively predicted national HIV prevalence. These
results support the hypothesis that HIV prevalence is lower among
Muslims. These results discount alternative explanations based on the
timing of HIV exposure (i.e., that HIV-1 appears to have evolved in westcentral
Africa and HIV-2 in West Africa: Holmes, 2001) or HIV
transmission increasing more readily among urban populations since the
results remain after controlling for such variables. That is, sub-Saharan
African countries with earlier dates of the first reported HIV case, or
more urban countries, did not have higher HIV prevalence. Moreover,
additional analysis revealed that within sub-Saharan African regions
(west, central, east, and southern), percentage Muslims and HIV
prevalence were negatively related in all four cases, but the small sample
sizes (e.g., six central African countries) argued against expanding on a
quantitative regional focus. The finding that per capita purchasing power
positively predicted HIV prevalence in the multivariate analysis is
interesting, but largely outside the scope of this paper. Nonetheless, one
possible reason for it could be that higher per capita purchasing powers
are linked with relatively greater economic costs to marriage (e.g.,
prohibitively expensive brideprices), leading to an increase in sexual
partners at the same time that formalised marital relationships decline
(see Blanc & Gage, 2000).
The data on risk factors associated with HIV portray a mixed picture with
respect to any protective benefits following from adherence to Islamic
codes. The data clearly show that these rules are not followed by
everyone, and in some cases do not appear to alter patterns of behaviour
by comparison with non-Muslim members of the same population. This
is especially the case with sexual activity (see also Gibney, Choudhury,
Khawaja, Sarker, & Vermund, 1999; Kagimu et al., 1998). In some cases,
Muslims do not appear to engage in less extramarital sex, for example,
than non-Muslims in the same population. On the other hand, there is
no evidence (discounting results in the Killewo, Dahlgren, and
Sandstrom (1994) study in Tanzania because these data did not directly
examine religious affiliation) that Islamic religious affiliation increases
sexual behaviours that constitute risk factors for HIV. The summary of
this evidence on sexual behaviour may be that the link between Islam
and sexual risk factors is ambiguous and varies among populations.
Through the practice of circumcision, which may reduce the risk of HIV
acquisition, and reduced consumption of alcohol (which might reduce
risky sexual behaviour though, note the discussion about sexual
behaviour above), adherence to Islamic tenets seems to reduce the risk of
HIV transmission. Consistent with this, Auvert et al. (2001) found that
factors unrelated to sexual behaviour accounted for differences in HIV
prevalence among four sub-Saharan African urban populations. Ritual
cleaning practices (e.g., after intercourse) may also decrease the chances
of sexually acquiring HIV. Higher degrees of polygyny, observed in two
studies, and a possible sentiment against condom use (noted in one
study) may increase the risks of HIV.
Conclusions
The hypothesis that Islamic religious affiliation is negatively associated
with HIV seropositivity is generally supported. The percentage of Muslims
negatively and significantly predicted the prevalence of HIV among sub-
Saharan African countries. Six of seven studies enabling withinpopulation
comparisons revealed lower HIV prevalence among Muslims.
Examination of HIV risk factors and HIV yielded more mixed results:
Islamic religious affiliation sometimes appeared to, but other times not to,
be associated with a reduction in sex outside marriage (e.g., with
commercial sex workers or within extramarital affairs). However, in no
study was Islamic affiliation positively associated with such sexual
behaviours. Muslims seemed to have lower alcohol consumption (which
might partly underlie any differences in risky sexual behaviour) and
higher rates of circumcision compared with non-Muslims, but Islam's
allowance for polygyny and discouragement of condom use would work
against reduced sexual transmission of HIV. Future discussions of the
predicted course of the global HIV epidemic may consider Islamic
religious affiliation as a socio-demographic factor associated with a
reduced risk of HIV transmission.
Acknowledgements
I thank Robert C. Bailey, Frank Marlowe, Martin Muller, Megan
O'Connell Gray, John Polk, Richard Sosis, and Richard Wrangham for
helpful feedback. For inspiring this research, I thank the men in Lamu,
Kenya who I interviewed during a project on marriage, parenting, work,
and hormones.
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Radiate_Truth · Joined: 18 Aug 2007 Posts: 1056

Aids and HIV are here now...
It does not discriminate against race, religion, sex or age group.
Lack of sexual health information and education are the biggest causes of transmitting disease.

obmar · Site Admin Joined: 14 Apr 2006 Posts: 5697

definitely.

Radiate_Truth · Joined: 18 Aug 2007 Posts: 1056

The point is I don't see what difference it makes who has it. All that matters is it needs to be treated. Disease does not care what color your skin is, what race you are or what religion you practice or your age, whether young or old or male or female, adult or child.

While they're or we're discussing this, more and more people are suffering or dying.

The Inquisitor · Joined: 17 Jun 2006 Posts: 772

RT,

You make some valid points, but I think the Harvard study was merely to see what relationship, if any, Islam had with HIV prevalence.

obmar · Site Admin Joined: 14 Apr 2006 Posts: 5697

jhoneferis · Joined: 09 Nov 2009 Posts: 4

Hi..
Ya I think so.. It may affect them.. Thanks for sharing your view...

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