Introduction

Globally, 38 million people live with HIV, 1.5 million people become infected yearly and about 34.7 million people have died from AIDS related illnesses since the start of the epidemic [1]. An estimated 40 percent of the new HIV infections worldwide occur among young people aged 15–24 years [2]. In addition, over 30% of all daily new infections are projected to occur among young people aged 15–24 years, with males and females disproportionately affected at 12% and 30% respectively [3]. Data from UNICEF shows that 460,000 young people (10–24) were newly infected with HIV [4]. Sub-Saharan Africa (SSA) bears the greatest burden of HIV/AIDS, accounting for the greatest number of new infections and deaths worldwide [5]. Young people account for approximately 20.6% of Uganda’s population [6] with a HIV a prevalence of 1.8% [7].

Young people (15–24 years) are particularly important because they bear the highest burden of HIV new infections [1]. In addition, young people are regarded as vulnerable because they tend to engage in the riskiest behaviors, such as engaging in sexual activity, amidst several challenges, including physiological changes, peer pressure, among others [8]. In this study, risky behaviors refer to behaviors characterized by different hazardous actions such as premarital sex, multiple sexual partners, and unprotected sex. In Uganda, HIV prevention interventions are aligned with the drivers of the epidemic. These include; delay sexual debut, elimination of unsafe sex, promoting correct and consistent condom use in the general population and high risk groups, reducing multiple, especially concurrent sexual partnerships, discourage cross-generational and transactional sex, wide coverage of safe male circumcision, reducing community viral load through anti-retroviral therapy and appropriate ARV prophylaxis [9, 10]. However, there is limited data on how effective these strategies have been especially among the young people. Some studies have reported early sexual debuts among students, which is a risk factor for sexually transmitted infections and HIV acquisition [11]. Uptake of HIV prevention services among young people is low and there is no gold standard intervention in regards to HIV prevention among young people in SSA [12, 13]. HIV prevention strategies for young people necessitate multifaceted interventions [14]. The national HIV prevention strategy recommends the use of all institutions including religious institutions to deliver HIV prevention messages and advocacy services to the general populations [10]. Previous research has suggested linkages between the involvements of Faith-Based Organizations (FBO) in campaigns to prevent HIV/AIDS [15, 16]. FBOs spend a large proportion of their time engaging with the community, thereby shaping social norms, attitudes, beliefs and people’s reality with regard to sexual self-understanding, making them crucial partners in HIV/AIDS prevention [17]. Some studies have reported mixed information about religious organizations at an institutional and individual level. The Catholic church for example has discouraged condom use and used stigmatizing language while at the same time religious leaders have been regarded as supportive [16]. Which makes the role of religious leaders unclear as an effective tool that can be used in HIV prevention among young people. For example, there is no evidence of studies that have evaluated to what extent religious leaders have played a role in HIV/AIDS prevention programme among young people as fundamental actors. Religious leaders in this study are individuals recognized as having authority within a specific religion, such as Pastors, Reverends, Bishops, Catechists, Priests, Sheikhs, and Imams. Uganda is a multi-denominational country, with approximately 82% of the population being Christians, 14% being Muslims, and less than 5% belonging to other religions, according to the 2014 national census [18]. Given the status religious leaders hold in many societies, they frequently have contact with communities and can utilize their pulpits to reach out to many, especially young people in hard-to-reach areas [19]. In addition, religious leaders can use their positions to break the silence surrounding HIV/AIDS, shape social values, disseminate accurate information and influence opinion [20]. However, the levels and intensity of engagement by religious leaders and how they are likely to influence the use of HIV prevention strategies among young people has not been studied.

HIV prevention strategies refer to ways in which individuals can reduce the risk of HIV infection by limiting exposure to risk factors. Condom use, safe male circumcision, pre-exposure prophylaxis (PrEP), elimination of mother-to-child transmission (EMTCT), testing and counseling for HIV and sexually transmitted infections (STI) have been adopted as some of the HIV prevention strategies. However, there is a paucity of information regarding how religious leaders can play a role in preventing HIV among young people. Evidence from a similar setting focused on religious leaders’ involvement in HIV prevention and care for gays, bisexual men, and others who have sex with men [21]. Some studies have only looked at involving religious leaders in HIV care and treatment at health facilities [22]. Because of the importance of religious beliefs in the prevention of HIV/AIDS, it is critical to assess religious leaders’ roles in the use of HIV prevention strategies among young people in Lira district. This study has generated evidence-based data for programming to improve the involvement of religious leaders in the use of HIV prevention strategies among young people.

Methods

Results

Social demographic characteristics of the respondents

A total of 422 participants were interviewed using an interviewer administered questionnaire with a 100% response rate. The mean age of the respondents was 19.18 (SD = ±2.6) with 56.9% (240/422) in the age category of less than 20 years. About 71.8% (303/422) of the respondents were single and 57.1% (241/422) were female. The majority of respondents, 45% (190/422), had completed an ordinary level of education (Table 1).

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Table 1. Shows the young peoples’ socio-demographic characteristics.

https://doi.org/10.1371/journal.pone.0276801.t001

HIV prevention strategies provided by religious leaders

The majority of participants, 85% (362/422), reported that their religious leaders advocate for abstinence. In addition, the majority, 95% (401/422) of the participants, reported that their religious leaders advocated for faithfulness (Table 2). Participants in the qualitative interviews strongly supported or advocated for abstinence, particularly among unmarried young people, and for being faithful to one partner among married people. One respondent reported that:

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Table 2. Perceptions and HIV prevention strategies provided by religious leaders.

https://doi.org/10.1371/journal.pone.0276801.t002

"Abstinence is the best. We discourage premarital sex for two reasons: one, you don’t go when there isn’t time, and there is time for everything. Sex is good, but in a marriage setting, it’s inappropriate. "So, according to Galatians 5:19, we reject and condemn fornication among young people, and we discourage and condemn adultery. “The only good way is abstinence and patience. "Male, SDA, R16, 38 years, March 2021.

As far as condom use is concerned, religious leaders have varying opinions concerning their support for condom use. Therefore, the message regarding condom use as one of the HIV prevention strategies by religious leaders cannot be ignored. A significant proportion, 71.8% (303/422) of the respondents, reported that their religious leaders discouraged condom use (Table 2). This result was further supported by a section of religious leaders who reported discouraging condom use among young people. Those who don’t support condom use argue that it promotes fornication and adultery among the youth. Some of the key informants remarked:

"Using condoms is not good for them because it allows them to engage in sexual relationships, which can easily lead to the spread of HIV/AIDS among young people” When you read Exodus 20 in the Bible, it talks about avoiding fornication, and the church teaches the youth not to engage in sexual relationships”. Male, SDA, R12, 50 years, March 2021.

According to another key informant:

"... Because of respecting the law, just like I swore, it makes me accept what the church has accepted. But what the church has refused, I will also refuse" Male, Catholic, R5, 30 years, March 2021.

A level of ambivalence was articulated by one of the key informants who was able to detach himself from his religion and reported he would encourage young people to use condoms because it would prevent them from contracting the virus, as quoted below:

".... "Leaving aside the issue of being a catechist, it is to advise a child to go to the hospital and get a condom in order to prevent a child from contracting the virus" Male, Catholic, R6, 42 years, March 2021.

About 51.2% (216/422) reported that their religious leaders have never advocated for voluntary medical male circumcision (Table 2). According to some qualitative interview participants, male circumcision is not a safer method of HIV prevention among young people, as one can still contract the disease and it encourages sexual relationships. One religious leader said:

"It makes one have uncontrollable sexual behavior." Male, Anglican, R11, 46 years, March 2021.

A significant proportion of participants, 65.2% (275/422), reported that their religious leaders preach about HIV prevention. The same message was echoed by participants in the key informant’s interviews. One participant reported:

"We preach to them and we encourage them to carry out tests to know their status as well. For those that already know their status, we always give them words of hope that that’s not the end of life" Male, Anglican, R19, 39 years.

About 61.9% (261/422) of the respondents reported that their religious leaders are involved in awareness creation programs among young people (Table 2). A section of the religious leaders reported not having posters/charts with HIV prevention messages in their various places of worship. If they are available, some people prefer to hang them in their places of worship. One participant was quoted as saying;

"...So my opinion is that it should not be hung against the wall in the church because it’s the house of the Lord, but it can be hung outside the church in the compound." Female, Pentecostal, R4, 50 years, March 2021.

The majority, 47.4% (200/422) of young people, reported that religious leaders have a strong influence on their use of HIV prevention strategies. A significant number, 47.9% (202/422) reported that religious leaders’ preaching influences their choice of HIV prevention strategy. Moreover, most 61.9% (261/422) of the participants reported that their religious leaders are involved in HIV/AIDS awareness campaigns (Table 2). This result is consistent with the results of the key informant’s interviews. One participant reported:

They have training most of the time during camp meetings, in the 13th week,........... and the church also organizes youth meetings once a month. We also have an Adventist Youth group that we teach about the dangers and prevention of HIV/AIDS, and we have books like ’Free from Addiction’ that we give people to read about HIV/AIDS." All of these programs are aimed at youths as well. "Male, SDA, R12, 50 years.

All the religious leaders interviewed had similar views on safe male circumcision as an HIV prevention strategy, except one respondent who had a different view. In his words he noted that;

“One thing that we as the church do not encourage is circumcision because it makes one to have an uncontrollable sexual behavior.” Male, Anglican, R11, 46 years, March 2021.

Bivariate and multivariable logistic regression of factors associated with use of HIV prevention strategies among young people

Factors significantly associated with the use of HIV prevention include completion of the primary level (aOR 4.95, p< 0.05), completion of at least A level (aOR 8.85, p<0.05), awareness of HIV prevention strategies by religious leaders (aOR 0.02, p<0.001), provision of HIV prevention messages from religious leaders (aOR 2.53, p<0.01), Advocacy for being faithful (aOR 35.6, p<0.01), Religious leaders preaching about HIV prevention (aOR 4.88, p<0.001) (Table 3).

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Table 3. Bivariate and multivariable logistic regression of factors associated with use of HIV prevention strategies among young people.

https://doi.org/10.1371/journal.pone.0276801.t003

Discussion

In our study in which we assessed the utilization of HIV prevention strategies provided by religious leaders among young people, we found nearly 70% of the participants reported using these HIV prevention strategies. In these settings, religious leaders are held in high esteem and they are viewed as trustworthy sources of information and guidance and compliance with their teaching could help prevent HIV among young people. This finding is consistent with other evidence where it is believed that religious leaders teach values whose obedience is likely to protect communities against HIV/AIDS [27]. In addition, evidence from elsewhere shows that religious leaders can help in the dissemination of health information, more specifically HIV prevention, to the communities that they serve [25, 28]. In other settings, however, some religious leaders have been reprimanded by their religious authorities and censored for preaching to their congregants on the subject of HIV/AIDS [29]. These actions are often driven by the negative association between HIV/AIDS and immorality, particularly in the form of promiscuity, and could impede progress in the fight against HIV. Furthermore, religious leaders have been accused of spreading false information; for example, making claims that prayers can heal HIV [28, 30] and unhealthy attitudes and behaviors create a barrier to prevention success among young people [31]. Among some religious leaders, HIV/AIDS is considered God’s punishment for sins such as being sexually promiscuous [32]. This implies that some religious leaders simply do not have the requisite knowledge of HIV/AIDS and its prevention.

The religious leaders’ creation of awareness was one of the reasons for the high utilization of HIV prevention strategies among young people. Our results also show that about 61.9% of young people reported that their religious leaders are involved in HIV/AIDS awareness campaigns. Our results also show that about 61.9% of the young people reported that their religious leaders are involved in HIV/AIDS awareness campaigns. This could be attributed to the fact that some religions are actively involved in HIV prevention, care and management [33]. Furthermore, some religious leaders stated that they organize workshops and seminars to teach young people about HIV prevention. This finding is in line with evidence from Senegal, where religious leaders were more likely to report teaching prevention [25]. Awareness created through religious engagements is likely to impact positively on the fight against HIV/AIDS among young people. In addition, those who were aware of HIV prevention strategies were more likely to use HIV prevention strategies as opposed to those who were not. These findings are consistent with data from other settings [34].

Our results also indicate that young people who were preached to about HIV prevention were more likely to use HIV prevention strategies provided by religious leaders. Preaching would lead to awareness creation, which empowers young people to be able to make better decisions as far as HIV prevention is concerned. Religious leaders are considered as moral authorities in their settings, and can be given platforms during religious gatherings, funerals, marriages and ceremonies, to preach about appropriate sexual behavior and other significant information regarding HIV prevention [35, 36]. Moreover, this finding is consistent with evidence from Malawi, where preaching about AIDS is a common activity for HIV prevention [21, 33, 37].

In our study, abstinence outside marriage and being faithful among the married were the most advocated strategies by religious leaders. Younger people whose religious leaders preached about abstinence and fidelity were 35.6 times more likely to use HIV prevention strategies compared to those who were not. Preaching is likely to result in more religiously enhanced behaviors that are beneficial to HIV prevention and lead to a constructive reduction in HIV spread and lower HIV prevalence [32, 38–40]. This is because abstinence and fidelity are rooted in most religious beliefs, and such values have the potential to lower the risk of HIV acquisition. The Holy Bible, for example, forbids adultery and fornication (Galatians 5:19). Our findings are consistent with what other scholars have observed elsewhere where sexual abstinence and mutual fidelity are encouraged as opposed to condom use that is viewed as undermining morality [28, 34]. This suggests that religious leaders place a greater emphasis on behavioral mechanisms, which are an important part of enforcing social values.

Our findings indicate that only 28% of young people reported their religious leaders advocating for condom use. Additionally, a huge proportion of religious leaders are not in favor of condoms being used as a prevention strategy. Condom use is viewed as a promotion of sexual immorality in many religious faiths, and in most cases, faith-based organizations have been reported to demonize condom use as promoting sinful behavior [35]. Catholicism, for example, forbids the use of condoms, even as a method of family planning. This finding is also consistent with evidence observed by other scholars in other settings [24, 25, 37, 41]. Nevertheless, some of the religious leaders in this study were able to detach themselves from their religions. For example, a section of religious leaders reported that they would advise young people to use condoms even though it is against the beliefs of their religion. As one respondent said, "many ways of HIV AIDS prevention are there, like condom use, but the church does not encourage this.

Religious leaders have shown a willingness to learn about and participate in HIV prevention in some settings, proving to be a valuable partner in the fight against the pandemic [21, 31, 34, 37, 42]. Over the years, efforts have been made to involve religious leaders in addressing issues related to HIV/AIDs. For example, an inter-religious project that provides training for religious leaders with scientific information supported by both Muslim and Christian faith teachings was piloted in 1995 and has evolved to address several HIV-related community needs [32]. However, according to some religious leaders in our qualitative results, their role was limited by a lack of training, inadequate equipment and facilitation to carry out HIV prevention programs. Similar results were obtained from a study in Nigeria [29].

However, our study had some limitations. Our data did not include the Traditional African Religious (TAR) leaders. The focus of our study was on modern religious leaders because it was challenging to detach the TAR leaders from their traditional beliefs from their spiritual components. Qualitative data collection relied heavily on KIIs that are prone to recall and respondent bias. In addition, we were unable to assess the age of initiation into sex, which would have been a good indicator of the level of risk. We did not assess the effect of other prevention strategies, for example, the media, and peer education. These are potential areas of future research in a similar setting. This study, on the other hand, was able to separate religious leaders from their religious affiliations, at least in some cases. And it highlights the importance of religious leaders and their readiness to participate in HIV prevention among young people

Conclusion and recommendations

We have found that religious leaders can play a pivotal role in HIV prevention among young people. The predictors of use of HIV prevention strategies provided by religious leaders include completion of an advanced level of education, awareness of HIV prevention strategies by religious leaders, provision of HIV prevention messages from religious leaders, advocacy for being faithful and religious leaders preaching about HIV prevention. Our study resonates with previous findings and builds on existing literature to highlight the role of religious leaders in the use of HIV prevention strategies among young people in resource-constrained settings. The benefit of the role of religious leaders is that they are considered as moral authorities in their settings, and are given platforms during religious gatherings, funerals, marriages and ceremonies, to educate them about appropriate sexual behavior and other significant information regarding HIV prevention. Efforts to train and harmonize key messages on HIV prevention messages, improved access to information, education, and communication (IEC) materials, and improvement in the level of education of young people will promote the use of HIV prevention strategies among young people.

Supporting information

Acknowledgments

We thank the study participants for taking the time to participate in this research. We also acknowledge the efforts of Dr. Wakida Edith and Ms. Guti Justine for the support they provided during this research project. Last we thank Dr. Ocan Moses and Mr. Opio Bosco for their technical input during analysis and drafting of the manuscript.