Faith-Based Organization Services as the Best Means to Prevent HIV and AIDS in Southern Cameroons

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List of Abbreviations

• Faith-based organizations – FBOs
• Behavior Change Communication – BCC
• Men who have sex with men – MSM
• Cameroon Baptist Convention Health Board – CBCHB
• The Abstinence Be faithful, and Condom use ABC
• Mother to child transmission – MTCT
• Nongovernment organizations – NGOs

Abstract

The HIV/AIDS epidemic in Cameroon remained to be a pressing issue for policymakers and the healthcare system. The most recent data suggested that in 2004 5.1% of the population had been infected. This was the largest percentage in the region of West and Central Africa. The HIV/AIDS issue was complicated by the fact that at the moment of this research, there was no cure and the only way of addressing the infection spread was through prevention and ensuring that people engage in behaviors that do not put them under the risk of contracting HIV/AIDS. In this paper, the author argued that FBOs are the best choice for implementing the strategies focusing on prevention because they had the infrastructure and resources to change the socio-cultural values of communities, which was what needed to be done to reduce the prevalence of HIV/AIDS cases in Cameroon. Apart from the health-related issues, caused by HIV/AIDS, the social stigma associated with the disease decreases the quality of life of the infected individuals. FBOs were one of not many forces that could be leveraged when addressing the HIV/AIDS epidemic because ministries and churches have a strong global impact, while simultaneously being closely linked to local communities. Moreover, in Cameroon, religious organizations were responsible for many of the state’s healthcare facilities. The findings from the review of the literature suggested that not many peer-reviewed articles on the topic of FBOs and their contribution to the reduction of HIV/AIDS cases exist, which was an issue considering that a typical Cameroonian family values religion as one of the essential practices. Hence, the government of Cameroon and NGOs had to support FBOs in their battle against the epidemic. Most importantly, one should understand that raising awareness and promoting education as a sole tool in the fight against HIV/AIDS was not enough, it is an essential part of the strategy but not the sole element of it. There was a need to implement model laws to protect people, who live with HIV/AIDS and a need to establish practices that reduce MTCT.

Introduction

Cameroon still has a relatively high HIV/AIDS infection rate of 3.8%. The epidemic is still a global problem and treatment efforts should focus on Cameroon because it was the hardest-hit region in the west and central Africa in 2004 (UNAIDS/WHO, 2004; Plan, 2019). It is one of the world’s least prosperous countries in terms of progress towards the UNAIDS 90-90-90 targets of Population-based HIV Impact Assessment, despite all attempts to mitigate HIV/AIDS risks (PEPFAR Progress Reports, 2018). As per my research findings, this is because the government has not given religion the place it deserves in its fight against HIV/AIDS (O’Donnell, 2018). The problem of HIV/AIDS in Cameroon hinders the state’s opportunity for achieving sustainable development because it burdens the health system and is accompanied by stigma that people living with this virus face, which can only be addressed by supporting the FBOs, promoting the knowledge of adequate behaviors, and implementing model laws.

The focus of this study is former Southern Cameroon. The location that is the focus of this research has one of the highest rates of HIV infection cases by region. Southern Cameroonians are poor, marginalized, and presently undergoing unimaginable political upheavals. The CBCHS, the FBO that has partnered with the government to fight against HIV/AIDS because these organizations originated here and are well-grounded in those communities. Figure 1 shows the distribution of HIV by regions in Cameroon.

A well-known researcher of religion, spirituality, and health defines faith as the practices and rituals related to the sacred (Koenig, 2009). These practices and traditions are prevalent in Islam, Christianity, and indigenous beliefs in southern Cameroon (Schilder, 1988). The HIV/AIDS information kit, jointly produced by UNICEF, UNAIDS, and the World Conference of Religions for Peace, urges leaders of various faith communities to use their influence, moral compass, and resources to alter the course of the epidemic (UNICEF, 2003).

For example, in one report, it is stated that “the church calls on men and women of goodwill to put all hands-on deck to wage an all-out war against this pandemic, by taking part in public sensitization, information, and education activities, without hesitating to fall back on our cultural and spiritual values” (NECC, 1999, p. 55). This quote implies that Cameroon’s cultural and spiritual values are indispensable in all HIV/AIDS discussions.

Faith-based groups in underserved neighborhoods have been essential catalysts of health and wellness campaigns (Campbell et al., 2007). Faith-based organizations (FBOs) include churches, mosques, and community-based organizations that use faith to spread moral values (Stewart, 2019). The Cameroon Baptist Convention Health Services (CBCHS) is a prominent FBO. It is a robust health care organization fostering HIV care and treatment initiatives in sub-Saharan Africa. Moreover, CBCHS is a critical partner of the Cameroon government working on the prevention of mother-to-child HIV transmission (Tih, 2018). CBCHS was slow in terms of embracing evidence-based practices (EBPs), making their work less effective, despite all the efforts to eradicate HIV/AIDS. Incorporating EBPs into new and existing FBO programs can improve their effectiveness (Terry et al., 2015).

FBOs’ importance in combating HIV/AIDS has been very much appreciated because churches have demonstrated that FBO credibility, influence, and strength in the community can positively change people’s behavior (Ochillo et al., 2017). The FBOs are invaluable actors in HIV elimination. They need more funding to focus on delivering much-needed lifesaving help to as many patients as possible (Ochillo et al., 2017). Many other African countries have used FBOs in the successful management of HIV/AIDS. For instance, Uganda is one of earliest and highly compelling national success stories in the world, where the president used FBOs to combat the spread of HIV (UNAIDS, 2004). In this research, I will use interviews with key informants as the basis for gathering information on FBOs impact. In addition, I will use information gathered from social media and literature on the topic, including reports from NGOs and case studies from other African states.

Engaging organizations with the capacity to reach large numbers of underprivileged individuals, especially those with health challenges, and the opportunity to impact individuals and their communities is a significant step in combating HIV (Schoenberg, 2017).

The CBCHS originated in southern Cameroons, and it is very popular, which is why this organisation is included in this research. Southern Cameroon has one of the highest numbers of HIV cases in this region, which is why this organization was selected for this research. Cameroon’s citizens are poor, marginalized, and presently undergoing political upheavals. This paper emphasizes that if FBOs incorporate EBP in their services, they will become the most influential institutions promoting preventive behaviors for HIV/AIDS in Southern Cameroon. One of the reasons for focusing on FBOs instead of government institutions is that the government has lost its credibility and moral authority to manage public and charitable institutions due to poor governance, corruption, and ineptitude (O’Donnell, 2018).

In this research, I ask the question of whether FBOs are the best solution for addressing the issue of HIV/AIDS in Cameroon. The premise is that for a Cameroonian society, FBOs are the important institutions that have an impact on society as religion is highly respected in Cameroon. Moreover, the government is not equipped to combat the spread of HIV because of corruption and improper management of resources. Hence, with this research, I ask the question of FBOs’ capability to address the HIV/AIDS epidemic in Cameroon considering the CBCHS’s use of evidence-based practices during their ceremonies and preaching for preventing behaviors that put a person at risk of contracting HIV.

Outline

This paper is structured with a goal of explaining the background information on Cameroon, the socio-cultural, economic, and political environments, which will be done in the section “Motivation.” Next, I will explain the methodology of this research, including how I selected the literature for this study and what additional sources of information I used. Next, in the section dedicated to the literature review, I will focus on the best practices and case studies, and I will explain why FBOs are suitable for the intervention I propose. In the final sections, I will summarize this paper, discuss the strategies that one can use in Cameroon to address the HIV/AIDS epidemic, and reflect on the experiences I gained with this capstone.

Motivation

The desire to research the religious aspects of managing HIV/AIDS in Southern Cameroon is personal. It was typified by Albert Einstein, who argued that “science without religion is lame, and religion without science is blind” (Bednar, 2016, p. 217). I have seen miracle healings that doctors cannot attribute any scientific rationale to in my job as a bedside registered nurse. If no scientific explanation exists, the interplay of both science and faith takes precedence. These inexplicable healings lead one to believe that religion contributes to holistic recovery. It is crucial for healthcare professionals and pastoral counselors to work together for holistic treatment. Secondly, the unique nature of the HIV pandemic is worth the research. It “hits adults in the prime of their lives, thus depriving families, communities, and the entire nation of their most productive citizens” (Niebuhr et al., 2004, p. 10).

Study Area

Brief History of Cameroon

Cameroon has a population of 26 million, with a surface area of 183,521 square miles, is located west of central Africa (World Population Review, 2020). Its neighbors are the Gulf of Guinea, in the southwest; Nigeria in the northwest; Chad in the North; the Central African Republic in the Southeast; with Congo Brazzaville, Gabon, and Equatorial Guinea all located south of Cameroon. Yaoundé is the capital of Cameroon, with Douala being its largest city (Washington Post, 2005). The country has ten administrative regions and eight of them are French speaking, while two are English speaking.

Political, Economic, and Social Development

Cameroon is governed by the 1972 constitution, which has been undermined by its various amendments (Malah, 2009). The president of Cameroon, whose name is Paul Biya, was born in 1933. He became president in 1982 and is still the president now at 87. He has been in power for 38 years (Drew, 2019). In 2008 he persuaded parliament to revise the constitution that made him the head of state for life. The revised constitution says, “the President of the Republic shall be elected for a term of office of seven years. He shall be eligible for re-election” (Cameroon 1972 rev., 2008, p. 6). Malah is therefore correct when she states that, “in the absence of any limits or restrictions on the amendment of a constitution, it is challenging for such a constitution to promote constitutionalism, respect for the rule of law, democracy, and good governance” (Malah, 2009, p.1).

The president appoints the head of government, who is the prime minister. The bicameral legislature consists of 180 seats in the national assembly and 100 seats in the Senate. These 100 seats are distributed equally among the ten regions. Of that number, 70 go through elections while the president of the republic appoints 30. The ruling political party, the Cameroon People’s Democratic Movement (CPDM), controls 148 of the National Assembly’s 180 seats and 81 of the Senate’s 100 seats (World Bank, 2020). Therefore, Cameroon is impaired in terms of its democracy — a situation often described as “the incapacities of governmental institutions to reflect the real values and ideas of the citizens” (Tronto, 2013, p.17).

As of 2015, before the strike in Cameroon, Cameroon had an index of 0.518 %, a ranking of 153 out of 188 countries, as evidenced in the Human Development Index (HDI), which calculates a country’s health, education, and income as indicators of development, (World Bank, 2015). This index placed Cameroon as a lower-middle-income country due to its dysfunctional educational system, poverty, mismanagement, and inadequate healthcare.

These political and social issues, coupled with its dysfunctional judiciary, and a very primitive infrastructure, weigh heavily on the former Southern Cameroons and propels it into abject poverty. Tertiary education focuses on conventional academic disciplines are inferior to modern times (World Bank, 2015). In November 2016, Southern Cameroon lawyers, teachers, and university students, who were frustrated with the existing system, went on a peaceful strike, protesting the adulteration of their Anglo-Saxon culture by the French culture (Foretia, 2017). Since then, Southern Cameroon has not known peace as tensions between the anglophone minority and the central government erupted into violence, with both sides committing atrocities (Chinje, 2017). More than 500,000 people are internally displaced, and approximately 400 civilians and over 200 military, gendarmerie, and police officers have died. Cameroon suffers from poor governance, which hinders its growth and investment capacity (World Bank, 2018).

Cameroon is a lower-middle-income country endowed with rich natural resources. Oil and gas are mainly located in Southern Cameroon and account for 40% of the country’s exports (World Bank, 2018). Cameroon had a significant economic crisis in the 1980s, which still affects its population to date. Rampant corruption has significantly reduced Cameroon’s economic development and adversely affected industry, employment, investment, economic growth, and development. In any civilization, corruption is detrimental to economic progress. Rampant corruption, coupled with government ineptitude and mismanagement, has stifled Cameroon’s economic growth and impoverished its citizens (Sumah, 2018).

Similarly to other public domains in Cameroon, healthcare is in a poor state for a country that has been independent since 1960. Access to quality healthcare is a nightmare due to the cost of services, systemic corruption, long distances to facilities, primitive infrastructure, limited trained personnel, and overt bribery or corruption. The government’s inability to satisfy its people is apparent in the fight against HIV/AIDS.

The current 28,000 newly infected persons with HIV far outstrip the 24,000 reductions in HIV-related morbidity and mortality (UNAIDS, 2018). The Cameroon government does not take serious steps to ensure that its citizens know their HIV status and “without a supportive partner, country policy environment (the presence of formal and informal regressive fees for health services), U.S. government HIV investments cannot be as effective or efficient, thereby slowing or stalling progress” (PEPFAR annual report, 2018, p.9). Cameroon stands out in central Africa as a glaring example of a country that lacks collaboration as well as the accountability of its partner governments and communities. Figure 4 below shows Cameroon’s position in 2018 among other states when comparing the percentage of people aware of their HIV status, treated or virally suppressed.

Progress toward UNAIDS 90-90-90 targets in adults in PHIA (Population-based HIV Impact Assessment) countries.

Many non-governmental organizations (NGOs) have stepped into the fight against the prevention of HIV infections. The most prominent is the CBCHS, a robust health care organization now working to reduce and, hopefully, improve HIV care and treatment in sub-Saharan Africa (Tih, 2018). The CBCHS is a faith-based-organization (FBO), a subset of NGOs. These FBOs are religious organizations existing in communities with religious and educational missions that provide social services and work autonomously but collaborate with at least some groups. Such organizations are sometimes called faith-based social service coalitions or religious non-profit organizations (Ebaugh, Chafetz & Pipes, 2006). The FBO (CBCHS) was established more than 60 years ago, in the small town of Donga-Mantung in the North West region of Cameroon. Today, this organization has branches in seven regions of the country and offers services countrywide. Figure 5 below shows the spread of CBHS in Cameroon.

The CBCHS employs 4000 people and has years of experience managing externally funded projects (Tih, 2018). One of the most up-to-date CBCHS centers is the Yaoundé Resource Centre, which provides testing, capacity development, and project management tools and services.

Although this organization flourishes in the health sector and has crossed several milestones, they face many challenges, such as poverty, unreliable communication networks, inadequate infrastructure, and a chronically unskilled workforce as Figure 6 illustrates.

Methodology

The literature review was conducted using the University’s online library resource, and the keywords for the search were “Cameroon HIV/AIDS,” “the epidemic of HIV/AIDS in Africa,” “faith-based organizations HIV/AIDS.” The final keyword, in particular, generated a large number of search results. Still, a very limited number of articles were written about Cameroon, limiting the applicability of findings since Cameroonians are religious people, and considering the corruption within this state, FBOs play a role in providing healthcare services and support to the communities.

This paper’s inclusion criteria include the relevance of the study to the research question, the publication date, which had to be within the last ten years, and the studies that described the best practices and success stories of other states were preferred. Governmental reports and case studies were included in particular because these allow reviewing empirical data, such as the number of cases before and after and specific steps in terms of policies and strategies that allowed FBOs to succeed in the region. The exclusion criteria were the origin of these reports and case studies, and papers that were not about Africa were excluded.

In total, I reviewed over a hundred articles and publications from NGOs and compiled the information from these resources into a literature review. In addition to the literature review, I communicated with the NGOs and governmental organizations that work towards reducing the number of infection cases in this state used my personal experience and data obtained from communications with people living in Cameroon.

Therefore, this research project draws on 2019-2020 data gathered from the literature review, case study reviews, primary informant interviews, and social media conversations to explore the integration of evidence-based practices (EBPs) on faith-based organizations (FBOs) programs as a safer response to HIV prevention in former West Cameroon.

I was born and raised in Cameroon, I participated in Baptist church services for three months while assisting my late sister in one of the CBCHS hospitals in Mbingo in the Northwest region. I also helped her brother during eye surgery in the Baptist hospital, Mutengene, in the southwest region. I was treated in government hospitals whenever I needed medical care. I therefore have some prior knowledge about how Baptist and government hospitals in this region function.

Critical Literature Review (CLR)

A scoping literature analysis was used to understand how FBOs handled HIV prevention in Cameroon properly. The most up-to-date literature released by September 2020 was selected from various databases. Sixty articles were reviewed and out of these, 15 topics were classified as key themes. A total of 75 scholarly articles were identified. All the search results were rechecked, and those who did not address evidence-based practices in FBOs, faith-based HIV preventive services, HIV in Cameroon, the case study of EBP in HIV therapy were eliminated. This repository of knowledge will be applied to determine if the government abdicated its responsibilities by relegating HIV preventive measures to FBOs.

Case Study Reviews

Multiple case studies were scoped by examining best practices from 18 countries in Central and West Africa, as outlined in the Aware HIV/AIDS 2011 project (AWARE, 2011). These studies offered an in-depth and thorough investigation of EBP and the related contextual information. They clarified the understanding of this complex issue of EBP on HIV prevention. Though there is no unique definition of a case study, Gustafsson (2017) and Woods (1980), in their research, define it as an intensive and systematic examination of a group, community, or some other social unit, where the researcher examines detailed data relating to several variables.

Key Informant Interview

An open and ongoing communication line with some members of the National AIDS Committee, NGOs, and employees in government-owned hospitals and hospitals run by FBOs in Cameroon has been maintained throughout this research initiative. Open-ended, unstructured interviews with key informants in Cameroon have also been conducted. Unstructured interviews involve the interviewer and researcher in a dialogue about the issue in reaction to the interviewer’s open-ended questions (Streubert & Carpenter, 1999).

The interview subjects were a small group of people who were likely to provide needed information, ideas, and insights on the research topic. Five analysis questions pertinent to this research project’s fundamental concerns were used. A review guide that lists the key issues and topics for each study issue has been prepared. Fifteen primary informants were chosen based on their experience and expertise. The research subjects were interviewed, and their responses were evaluated. All interviews were conducted with the full consent of the research participants.

Social Media

Data were obtained about corrupt practices currently taking place in Cameroon churches. The data were used to understand public opinions on what people think about eradicating HIV patients’ user fees. Two hundred randomly selected participants from the author’s alumni association volunteered to participate in an online debate, hosted by the author, about Cameroon HIV patients. This social media initiative was instrumental in providing gray literature for this research project.

Limitations to the Methodology

The research time was too short for a researcher to obtain adequate participant feedback. There was inadequate time to verify if the PEPFAR imposed government and FBOs laws passed in April 2020 on no user fees were effectively respected. Cameroon is currently under a political crisis. This crisis comes with many repercussions like unwarranted police arrests, mass killings of citizens by both parties, ghost towns imposed by both the government forces and the secessionists, and little or no internet services, thus limiting communication with the rest of the world. Communication was, therefore, a significant handicap, and even when the internet was restored, effective reliable communication was spotty, due to intermittent power outages for prolonged intervals.

Fifteen individuals served as sources of information during this project. It was challenging to validate the information received from these sources. Some sources appeared to be reliable based on their titles and socioeconomic standing, but they were not familiar with the local conditions. One standard error in key informant research is to choose informants based on their social and economic status or their fluency in an international language rather than on their knowledge of the local situation (Kumar, 1989). The French language constituted another impediment. Many articles in the French language needed an English translation and were not used.

The HIV/AIDS global pandemic generated too much data for easy analysis. Information obtained about Cameroon was mostly grey literature obtained through social media. Social media arguments were partial, and neither the government nor the secessionists wanted to take responsibility for the information contributed by them. There were, therefore, no objectively verifiable results, which is a weakness inherent in qualitative research methods (Choy, 2014).

Literature Review

Do FBOs in Cameroon follow best practices in the management of HIV/AIDS prevention?

Promising and Best Practice (PBP) can be defined as, “an experience, initiative or program that has proven its effectiveness and its contribution to the response to the HIV/AIDS epidemic, and that can serve as an example and inspiring model for others (program planners, managers, and implementers).” (AWARE HIV/AIDS, n.d., p.12). This is the definition that was adopted by AWARE-HIV/AIDS project. AWARE-HIV/AIDS is a regional project, sometimes referred to as a workshop that covered 18 African countries, which included sixteen countries in West Africa and two states in Central Africa, including Cameroon. Funded by USAID and applied by Family Health International (FHI) as an effort to promote PBP in the fight against STI and HIV/AIDS in this region. To be perceived as an EBP, the following elements should be outstanding and this program should be: “useful, relevant, effective, innovative, produce results within a reasonable time, efficient/cost-effective, ethically sound, and sustainable” (AWARE HIV/AIDS, n.d., p. 1).

Five technical areas and two policies were selected as PBP during the AWARE HIV/AIDS workshop in Dakar 2004. These technical areas and policies will be analyzed to see how effective its application has been in Cameroon. These policies are:

1. The engagement of religious authorities in the attempt to fight HIV/AIDS and,
2. A model law on HIV/AIDS.

Five technical areas in terms of designated best practices to be examined here are:

1. Behavior Change Communication (BCC),
2. Voluntary Counseling and Testing (VCT),
3. Sexually Transmitted Infections (STI),
4. Prevention of Mother-to-Child HIV Transmission (PMTCT)
5. Care and Treatment (C&T)

The author of this research will critically examine literature that deals with the ways of managing HIV in Cameroon following the PBP technical strategies and policies to come out with the role of FBOs in the process of managing the epidemic of HIV/AIDS in Cameroon.

Policy Change and Community Based Health Financing

Involve Religious Authorities (FBOs) to Fight against HIV/AIDS

FBOs exist in Cameroon and have been instrumental in HIV/AIDS cure and care. The work of FBOs in Cameroon presently cannot be overlooked. They operate health networks and are active partners in the national HIV/AIDS response in Cameroon (PEPFAR 2018). The Roman Catholic Church operates the most extensive health network, and the Cameroon Baptist Convention Health Services (CBCHS) works in collaboration with the United States Government (USG) to help prevent mother to child transmission (PMTCT). The Presbyterian and Seventh Day Adventists also have a vast network (PEPFAR 2018).

Professor Tih Pius, the director of the Cameroon Baptist Convention Health Services (CBCHS), also acknowledged that FBOs provide 30% to 70% of health care in most developing countries. (Tih, 2018). Some FBOs procure and distribute essential medicines to complement government systems, others do necessary testing, carry out preventive strategies, treat and cure, and fight against counterfeit and substandard drugs (Tih, 2018).

The Catholic relief services made its first appearance in Cameroon in 1961, adapting their program to the changing circumstances of the country and the needs of the Cameroon people. They initially worked to reduce the death rate of children under five, with a vision of improving food supply in the North of the country where there was drought-related hunger. Later, they moved to governance, health, and HIV programming. Currently, their focus is on supporting refugees, orphans, and vulnerable children and community health, including water and sanitation in Cameroon (CRS faith Action Results – Cameroon, n.d.).

CBCHS are at the forefront of the HIV/AIDS battle in Cameroon. The church started the medical branch in the 1930s but was only in 1975 that they became an FBO. CBCHS is an indigenous Cameroonian nonprofit organization with a mission to provide care to all individuals in need of it as a way of expressing Christian love. They address both clinical and public health problems affecting individuals and communities in Cameroon and Africa at large. They run five hospitals, 24 integrated health centers, and 50 primary health centers. In addition, the CBCHS works on the “prevention of mother to child transmission (PMTCT) and care and treatment (C&T)” while “CBCHS pharmaceutical produces and distributes a well comprehensive AIDS care and prevention program” (Bonje et al., 2012, p. 3). CBCHS’s services exist in seven out of ten regions in Cameroon, ranging from rural primary health care to highly specialized hospital-based care with an integration of other social services (Tih,2018). CBCHS partners with several national, international, governmental, and nongovernmental health-care organizations as well as with funding agencies throughout sub-Saharan Africa and globally. Therefore, CBCHS is a crucial partner to the government and is a leader in HIV/AIDS response in Cameroon.

The advocacy for FBOs to join the fight against HIV/AIDS is not new. The world council of churches advocated for churches to be transformed in the face of the HIV/AIDS crisis so that they may become a force for change and bring healing, hope, and comfort to all affected by HIV/AIDS. This is because churches have strengths and credibility, and they are grounded in communities. This connection with communities allows ministries to make a real difference in combating HIV/AIDS (Ibid). According to Kron (2012), the United States recognized the influence FBOs had over the prevention of HIV, and the state’s government revised its policy in 2003, teaming up with FBOs, and adopting the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) (Karon, 2012). Likewise, in 2014, CDC/PEPFAR funded the Local Capacity Initiative (LCI) project submitted by the CBCHB, which was tailored to respond to this project to scale up and improve the quality of HIV prevention of Mother-To-Child services in the Northwest and Southwest regions of Cameroon (CBCHB Free Projects, 2014). Similarly, Welty et al. (2005), prove that FBOs could be trusted and it is best practice to include them in the management of HIV/AIDS in Cameroon.

Model laws in HIV/AIDS

Africans infected with HIV/AIDS are usually deprived of their human rights. Children are usually denied education, and widows and orphans have difficulty when exercising their inheritance rights. Stigmatization and subsequent discrimination that are linked to HIV/AIDS push infected people into hiding. It was, therefore, essential to have an adequate legal framework to fight against HIV/AIDS-related stigmatization or discrimination (USAID, 2011). To address this, the leaders of eigteen West and Central African counties met in N’Djamena in September of 2004, to create a model law that was adopted by the participants with an objective to design “an action plan for the adaptation, adoption, and promotion of the Law” (USAID, 2011, p. 10). Benin’s Law 2005-31 came as a result of Leon Bio Bigous’ return from the 2004 N’Djamena workshop.

In Cameroon, no bill that addresses oppression and discrimination of people with HIV/AIDS has been adopted as such. However, Akonumbo (2006) identifies HIV/AIDS policies in Cameroon and legal considerations that help address this indirectly. The author gathers some of the significant challenges confronting or likely to face HIV/AIDS policies in the state. Cameroon depends on the international and regional legal framework for HIV/AIDS legislation. The primary Cameroonian texts governing HIV are those creating the institutions responsible for implementing HIV policies as well as those relating to specific cases, for instance, the anti-retroviral drugs (Akonumbo, 2006).

The sole legislation on HIV is the 2003 law regulating blood transfusion and a draft law targeting the rights and obligations of People living with HIV/AIDS (PLWHA). This notwithstanding, since “in the absence of specific HIV/AIDS legislation, the reading of relevant provisos in the revised Constitution of 1996, the Penal Code and case law, may help indicate the possible juristic approaches to HIV/AIDS in Cameroon” (Akonumbo, 2006 p. 92). These approach of model laws for HIV/AIDS as the best practice is criticized by many. In the research paper by Grace (2015), she said, “although best practice standardization has been a critical feature of global health institutions work activities in the HIV response over the past two decades, recent replications related to the criminalization of HIV transmission illustrate the potential public health dangers of ‘don’t reinvent the wheel’ thinking. I offer a normative critique of the transnational, text-mediated process that has produced highly problematic laws” (Grace, 2015, p. 441).

Five technical Strategies for HIV/AIDS (PBP) include the following: Behavior Change Communication (BCC), Voluntary Counseling and Testing (VCT), Sexually Transmitted Infections (STI), Prevention of Mother-to-Child HIV Transmission (PMTCT) and Care and Treatment (C&T)

Behavior Change Communication (BCC)

In the Communication for Behavioral Change in Sex Workers for the Prevention and Management of sexually transmitted infections (STI)/HIV/AIDS on Migratory Routes in Togo document, the authors state that “SISTER-TO-SISTER” project is a sexual BCC project selected as PBP which aims sex workers along the Lome – Cinkasse route. Also, “educators recruited from the target population of sex workers carry out social mobilization among their peers, in HIV/AIDS/STI prevention to change the perceptions of sex workers about the risks of infection, encourage proper and systematic use of male and female condoms for intercourse with clients or regular sexual partners, help their peers to have improved management of STIs, and easy access to voluntary counseling for HIV and to condoms at all sex work sites” (AWARE HIV/AIDS, 2011, para. 15). This project lasted four years under the supervision of the NGO FAMME funded by the Department for International Development United Kingdom (DFID). Literature reviews have always considered BCC as an essential step in social marketing on the prevention of HIV. Awasthi and Awasthi (2019) explain the various BCC movements that use mass media and have become useful in creating awareness and promoting a change for the better in one’s behavior for large populations over a short timeframe.

The BCC campaign carried out in Cameroon on HIV/AIDS was successful, as evidenced in the “100% Jeune” project campaign that was a social media campaign. This campaign in particular, “involved activities like peer education at multiple locations, a monthly magazine, information dissemination through an 18-episode drama, and call-in shows via the radio, television, billboards, and establishment of user-friendly condom outlets for users” (Awasthi & Awasthi, 2019, p. 80). Moreover, Meekers, Agha, and Klein (2005) concluded that for the BCC to affect the rates of condom use, the “100% Jeune” social marketing program should be repeated to be effective.

Voluntary Counseling and Testing (VCT)

The Strengthening Access to Voluntary Counseling and Testing for Young Students in Burkina Faso 2003 is the project that qualified the country as PBP on VCT, meaning that the example of Burkina Faso should be emulated by others. Every year, this initiative’s management organize a national HIV/AIDS voluntary testing campaign that can be done in schools and universities to enhance VCT in schools as well as to promote low-risk HIV/AIDS behaviors. This study was in line with several behavioral studies that also showed there are many cases of persistent risky behaviors in this area, infrequent condom uses, and sex between students and teachers in schools and university campuses despite the efforts to raise awareness about premature pregnancy and diseases risks. The active involvement of the Ministry of Education was the main contributor to this campaign (AWARE HIV/AIDS, 2011). Cameroon has not been highly successful in emulating the Burkina Faso VCT project. A literature review on VTC in Cameroon portrayed many reasons why VTC failed. Either the turnout of students was poor because it was costly as Haddison et al. (2012) note, or the students were not well sensitized and awareness and use of centers offering VCT for HIV were low (Ngwakongnwi & Quan, 2009). Lastly, the test results were not released the same day as the test (Ngangue et al., 2016).

Ngangue et al. (2016) identify factors that influence the quality of HIV counseling and testing services in district hospitals of the city of Douala, Cameroon. Findings range from inadequate infrastructure to ensuring the privacy and confidentiality of counseling, the client’s right to informed consent not being respected, and lack of prior consent. Counselors were not well trained, and test results were not given the same day as the tests (Ngangue et al. 2016).

Sexually Transmitted Infections (STIs)

Adapted Services for Sex Workers and their Sexual Partners: A Strategy to Reduce the Transmission and Minimize the Prevalence of HIV/AIDS is the project that made Benin a PBP. It “owes its efficiency to linking clinical care in adapted services with Behavior Change Communication (BCC), community outreach activities, consultation with security forces and sex work site owners, as well as regular follow-up activities” (AWARE HIV/AIDS, n.d., p. 34). These services included regular medical check-ups, fixed or advanced strategies for the active testing for STIs and their management, counseling, integrating the promotion of HIV voluntary testing and care targeting sex workers living with HIV, and prevention and care for other opportunistic infections. In Cameroon, STIs including HIV have been a central issue of public health challenges (Awuba & Macassa, 2007). Also, multi-country regional reviews conclude that despite prevention efforts, female sex workers (FSWs) remain one of the main populations affected by HIV/STIs, especially in Cameroon and Nigeria, two countries with the highest HIV and STI prevalence (Tukov, Jenevarius, & Ndzelen, 2016).

However, recent studies on STIs show that FSWs and men who have sex with men (MSM) carry high burdens of HIV, disproportionate to other populations. Still, they remain understudied and unsurveyed owing to legal, ethical, and social challenges (Bowring et al., 2019). MSMs have a higher probability of living with HIV than other adult men in low- and middle-income states. In Cameroon, they face barriers when accessing HIV services including a lack of specialized care and community-level stigma as well as discrimination (Holland et al., 2015). Therefore, policy development initiatives and programs to enhance sexual health knowledge and behavior among men would be helpful in reducing STI incidence in Cameroon. Currently, thousands of men in Yaounde have been convinced by sex workers to get tested in a project run by CARE International and local partners called Horizons Femmes (Lazareva, 2017).

Prevention of Mother-to-child HIV Transmission (PMTCT)

PMTCT was a Cameroonian project funded by EGPAF, implemented by CBCHB. CBCHB “began a PMTCT in 2 regions, intending to reduce the incidence of HIV infections in children by scaling up the PMTCT services in six of the ten regions of the country, covering at least 100,000 pregnant women by 2007” ( (“HIV Free project CBCHS,” 2019, p.44). The objective was to, “integrate PMTCT services into routine antenatal services in two regions by 2004; adopt a Community-Based Approach in Service Delivery (bottom-up approach); intensify training of trainers and raise the number of counselors from 21 in February 2000 to 500 by December 2005 and collaborate with the National AIDS Control Committee (NACC) in the training activities” (“HIV Free project CBCHS,” 2019, p.45). After 12 years, HIV seroprevalence decreased from an average of 10.3% in 2000 to 5.0% in 2011 among women tested in antenatal care and labor and delivery. A total of 40,265 women received ARV prophylaxis, as well as 21,345 infants (“End of project report – Cameroon,” 2012).

Globally, when implementation of PMTCT services prevented “around 1.4 million HIV infections among children between 2010 and 2018” (UNAIDS, 2018, p. 10). Despite the progress made through PMTCT, the pediatric HIV epidemic in Cameroon remains to be a major concern. Apart from this, policymakers need more information about the extent of the pediatric HIV epidemic (Nguefack et al., 2015). Nevertheless, authors of several reports point to the beneficial effect of male partner involvement in programs, which target the prevention of MTCT of HIV in reducing the number of pediatric HIV infections (Morfaw et al., 2013). Additionally, Fondoh and Mom (2017) report that the risks of MTCT when HIV-positive mothers were on cART were 2.49 times lower compared to women who were not on cART. Hence, maternal antiretroviral interventions should be addressed, and medical professionals should encourage HIV-positive pregnant women to use a combination of ART (cART).

Care and Treatment (C&T)

The Care for People Living with HIV through the Medical and Social Support Center is the project in Côte d’Ivoire AWARE participants admire as a PBE for providing care and treatment. The establishers of the Medical and Social Support Center (Centre d’Assistance SocioMédicale/CASM) created it to help decongest health facilities, at least partially, and aid in providing compassionate care to PLWHA. This facility serves as a bridge between PLWHA, their families, and their communities. This project was funded by HOPE Worldwide Côte d’Ivoire, an agency of HOPE Worldwide, an American faith-based nongovernmental organization, and this project benefits PLWHA and their families, regardless of their race, nationality, or religion.

In Cameroon, the Ministry of Social Affairs, other development partners, and the Ministry of Public Health try to provide care for HIV/AIDS orphans and vulnerable children (OVC). They provide psychosocial support, such as counseling to OVC and families, caregivers, as well as provide education and training, medical care, and income-generating activities. Integrated Foundation Development (IFD) and many partner NGOs are advocating for the training initiatives to empower the OVC population to fight for their rights.

IFD provides material support to OVC for necessities, for example, clothing, shoes, food, and other items. (Integrated Foundation Development, 2019). The practice of community care for the OVC population is widespread, for instance, the government, in partnership with the Global Fund, bilateral and multilateral organizations, and NGOs, support local communities in an effort to improve their capacity to care for OVC, including the creation of income-generating activities, which is the basis of community ownership and sustainability. The integrated care of the OVC population is possible in Cameroon. Unlike in Ivory Coast, in Cameroon, the Cameroonian government leads a continuous multi-sectional approach to solve the issue of OVC (Nsagha et al., 2012).

Argument: Using evidence-based practices, FBOs are the most effective institution for promoting preventive behaviors for HIV/AIDs in Cameroon:

• The FBO’s involvement in the African HIV/AIDS epidemic is the best method, an initiative that has proven its efficiency and its potential to contribute to the response to the HIV/AIDS epidemic. The incorporation of the evidence-based practices (EBPs) into FBOs’ service programs enhances their effectiveness (Terry et al., 2015). In this paper, the author argues that FBOs are the most effective institutions for promoting preventive behaviors for HIV/AIDS in Cameroon. This argument is valid because many governmental and nongovernmental organizations (NGOs) do not uphold the moral standards when managing governmental and charitable institutions, mainly due to poor governance and corruption (O’Donnell, 2018). In his doctoral dissertation, Lewis (2019) acknowledges that “government corruption in developing countries metastasizes like cancer, slowly capturing and then deteriorating the ability of government institutions to fulfill their promised duties”(p. ii). Similarly, according to the popular representations of politicians in Africa, a typical African head of state is corrupt, dictatorial, selfish, and problematically conservative (Essoh, 2020).
• FBOs have made great progress in managing HIV/AIDS spread globally, especially in the domain of prevention. The combination of prevention and the prayer doctrine acts as an enabler for compliance with the best practices and recommendations. The success of FBOs, a subset of NGOs, was recognized as valuable by President Clinton’s charitable initiatives in 1996 and President Bush’s initiatives in 2001 for FBOs, making FBOs a platform for sponsors (Hong, 2012). These evaluators have given FBOs a better grade than any other organization. An analysis of best practices of 52 studies reveals that use of faith, appropriate staffing, humanized leadership, and proper funding were the four critical factors that led to the best macro practices in FBOs (Hong, 2012). FBOs are significant providers of healthcare and support services to people, who live with HIV/AIDS around the world, and they spread education and prevention messages to the most remote villages.

The HIV/AIDS epidemic is still a global concern, and there is the need to target Cameroon because it was the hardest-hit region in West and Central Africa in 2004 and still has a relatively high incidence rate (UNAIDS/WHO 2004; Plan, 2019). Despite all attempts to mitigate HIV/AIDS, Cameroon is one of the least successful countries when evaluating the progress towards the UNAIDS 90-90-90 targets in Population-based HIV Impact Assessment PHIA (“PEPFAR progress reports,” 2018).

iii) The problem Cameroon is facing is not the lack of financial assistance, education, and counseling, or medication to treat its people, although the main problem is the governance of these resources. Two characteristics of good governance that set FBOs apart from most secular humanitarian organizations are their faith, which is a powerful motivation for humanitarian action, and their constituency, which is broad, and centers around the poor and the marginalized (Ferris, 2005).

Supporting arguments/claims

Political/Economic

FBOs instill greater trust and demonstrate less evidence of corruption in health interventions when compared to the Cameroonian government

Corruption. Corruption is a difficult concept to define because people look at it from varied perspectives (Nduku, 2015). One way of characterizing corruption is as mismanagement, lack of accountability, lack of transparency, bribery, embezzlement, injustice, immorality, the abuse of power, the colonization of social relations, conduct or practice in flagrant violation of existing rules and procedures, and as an evil that has challenged many societies in the world.

Corruption is a pressing issue in Cameroon, where the absence of good governance and the country’s abject poverty are huge obstacles to development (O’Donnell, 2018). The mismanagement of funds and the lack of accountability are significant setbacks to the progress of HIV prevention and treatment (Akonumbo, 2006).

Cameroon, in 1998 and 1999, was the most corrupt country in the world, according to the Corruption Perception Index (CPI) (Stückelberger, 2003). The 1998 CPI was a wake-up call to the Cameroon head of state to confront the country’s pervasive corruption. The CPI ranking led to the development of the first code of conduct to combat corruption and promote transparency in NGOs and churches in Africa, funded by the Bread for All initiative from Switzerland. The Anti-Corruption Clause for Contracts states that “the contractual parties shall neither offer a third person nor seek, accept or get promised directly or indirectly for themselves or for another party any gift or benefit which would or could be construed as an illegal or corrupt practice” (Stückelberger, 2003 p. 20). This code raised anti-corruption awareness among staff and board members of companies. It has also led to the brainstorming of new ideas for anti-corruption solutions and improved institutional structures such as separation of powers and controls, and many countries in Africa began to fight corruption.

The Catholic Bishops of Cameroon strongly condemned corruption in different sectors of the country’s governance in 1998. The 37th synod of the presbyterian church in Cameroon (PCC) accepted the government’s concern to combat corruption but urged the government to appoint people with proven moral integrity from the church to head the project and to sanction those who mismanaged public funds. The Cameroon Federation of Protestant Churches and Missions (FEMEC) published a booklet entitled “Jugulate Corruption” (FEMEC, 2000). A FEMEC youth forum created its own Code of Conduct on Corruption in August 2002.

In 2005, Cameroon showed a slight improvement by ranking137 out of 158 counties in CPI. This persistent mediocrity motivated the head of state to discreetly sack some officials of the National AIDS Control Council (NACC) for misappropriation of HIV/AIDS funds. In 2006, Cameroon showed slight improvement, ranking as 138 out of 163 countries surveyed (Akonumbo, 2006). That same year, ministers and former directors of state-owned corporations were arrested for fraud and misappropriation. Corruption is still rampant in Cameroon despite the government’s anti-corruption measures. If left unaddressed, corrupt practices and embezzlement of funds will not allow any meaningful HIV/AIDS mitigation initiative to succeed.

FBOs do actually play an important role in combating corruption and promoting justice (Nduku, 2015). They can be effective anti-corruption tools if they are allowed to work on their own terms. A research study conducted to find out if the level of religiosity in an institutional environment can affect the emergence of the corporate governance system in Nigeria revealed that religion had not stimulated the desired corporate governance because of prioritizing orders from the government over religious practices (Nakpodia et al., 2020). Though some empirical studies have suggested that African countries, similar to Cameroon, which have strong hierarchical religions, for example, Islam, Catholicism, or Orthodox Christianity, are more inclined to suffer from corruption, there is still no strong evidence in support for this correlation (Ko et al., 2014). However, FBOs foster religious ethics and advocate for human rights principles, and fighting corruption is part of these religious principles (Browne, 2014). Therefore, FBOs must be part of the anti-corruption efforts to free the exploited and marginalized people from the chains of poverty (Nduku, 2015). Currently, the involvement of Churches, other FBOs, development agencies, and mission networks show signs of progress in the anti-corruption domain.

User Fees Mismanagement

CBCHB is the FBO that cares for 97% of all patients on treatment in PEPFAR’s program, 94% of all new patients placed on treatment in FY18, and 97% of all viral load tests performed in Cameroon (Birx, 2019). They still collect user fees for HIV prevention and treatment. There is, therefore, a significant legal barrier that can only be resolved with a new government policy in place that allows the FBOs to work on their terms.

Evidence shows that removing user fees could improve service coverage and access, but this must be a well-calculated event because acting without prior preparation could lead to unintended effects, including compromising quality and excessive demand on health workers (McPake et al., 2011). Boyer et al. (2009) produced a typical expenditure statement of an HIV patient in Yaoundé, the capital of Cameroon, which reads:

“The median monthly direct out-of-pocket health expenditure of ART-treated patients was 9800 FCFA (IQR: 6300–18 600), or 20 US$ (IQR: 13–38). Of this amount, 3000 FCFA (IQR: 3000–7000), or 6 US$ (IQR: 6–14), went mainly to the purchase of ART; 1000 FCFA (IQR: 600–2,000), or 2 US$ (IQR: 1–4), went to transportation costs to the hospitals, and 1600 FCFA (IQR: 0–3,000), or 3 US$ (IQR: 0–6), went to healthcare professionals’ consulting fees. These amounts comprised 47.0%, 12.0%, and 6.0% of the total expenditure, respectively. Other expenditures went to medication other than ART, biological tests, hospitalization, and traditional medicine” (p. 4).

This article envisaged that “free-of-charge ART at the point of delivery,” as endorsed by the WHO, is one of the critical components for reaching “the goal of universal access to HIV/AIDS care and treatment by 2030” (Boyer et al., 2009, p. 4). Similarly, literature reviews on empirical evidence gathered since the 1980s clearly show that sustainability, efficiency, and equity problems faced by public health care systems in developing countries persist due to the introduction of user fees (James et al., 2005). There are reports, however, that free HIV outreach programs have expanded the utilization of prevention and care despite that the HIV/AIDS stigma remains burdensome (Desclaux et al., 2007; Eboko et al., 2010).

The financial burden of user fees leads to late diagnosis, late treatment, and an increased number of new infections. Luma et al. (2018) also confirm that the late start of HIV care is remarkably high at the Douala General Hospital (DGH), and it is associated with poor outcomes. According to a briefing to the U.S. Ambassador to Cameroon, Peter H. Barlerin, delivered by Ambassador Deborah Birx, it was reported that formal and informal patient fees remain commonplace in clinics in Cameroon. The Cameroon government does not have the resources to effectively treat patients who need constant life-saving treatments (Birx, 2019). Moreover, user fees have led to a drastic drop in patient retention from 79% in 2017 to 32% in 2018. While acknowledging the financial barriers imposed by user fees in an emergency context, there is consensus that essential health services during a humanitarian crisis should be provided free of charge at the point of delivery (Boyer et al., 2009). The preliminary progress that was made during the initial stages of a voucher program allowing to pay for the costs of these fees is much appreciated. However, this is not a long-term solution to eliminating user fees (Bix, 2019).

Consequently, on 4 April 2019, the Cameroon Minister of Health ordered the elimination of all HIV service fees in healthcare facilities. This is not the first time the Cameroon government has issued such legislation. The financial consequences of this decision were included in the 2020 Cameroon budget, and the funding for PEPFAR for COP 2019 and COP 2020 relied on the effective implementation of the abolition of user fees government-wide and on-site (Birx, 2019). If this new budget is professionally managed, CBCHB will stop collecting user fees, thereby improving HIV/AIDS prevention and care in Cameroon.

Data-Driven

There is evidence supporting the need to include FBOs in the strategy of combating HIV/AIDS as first-hand support.

FBOs Fight against HIV/AIDS in Cameroon

Cameroon FBOs have been instrumental in HIV/AIDS treatment and care. They run health networks and are active partners in the national HIV/AIDS response in Cameroon (PEPFAR 2018). The Roman Catholic Church runs the most extensive health network, and the CBCHS works in collaboration with the USG to help prevent MTCT. The Presbyterian and Seventh Day Adventists also have a considerable network (PEPFAR, 2018).

Professor Tih Pius, the Director of the CBCHS, also acknowledged that FBOs provide from 30% to 70% health care services in most developing countries (Tih, 2018). Some FBOs procure and distribute essential medicines to complement government systems, others do necessary testing, carry out preventive strategies, treat and cure, or fight against counterfeit and substandard drugs.

The Catholic relief services made its first appearance in Cameroon in 1961, adapting their program to the changing circumstances of the country and the needs of the Cameroon people. They initially worked to reduce the death rate of children under five, with a vision of upgrading food supply in the northern regions of the country, where there was drought-related hunger. Later, the relief services changed their strategy and worked on governance, health, and HIV programs. Currently, their focus is on supporting refugees, orphans, and vulnerable children and community health, including water and sanitation initiatives in Cameroon (“CRS faith Action Results – Cameroon,” n.d.).

CBCHS are at the front of the HIV/AIDS battle in Cameroon. The church started the medical branch in the 1930s but only in 1975, they became an FBO. CBCHS is an indigenous Cameroonian nonprofit organization, which declares a mission to provide care to all people, as a manifestation of Christian love. They address both clinical and public health problems affecting individuals and communities in Cameroon and Africa at large. They run five hospitals, 24 integrated health centers, and 50 primary health centers, “besides, with 13 components, including Prevention of mother to child transmission (PMTCT) and care and treatment (C&T), CBCHS pharmaceutical produces and distributes a well comprehensive AIDS care and prevention program” (Bonje et al., 2012, p.3). CBCHS’s services exist in seven out of ten regions in Cameroon, ranging from rural primary health care to highly specialized hospital-based care with an integration of other social services (Tih, 2018). CBCHS partner with national and international governmental and nongovernmental healthcare organizations and funding agencies throughout sub-Saharan Africa and globally. They form a crucial partner to the government and are the technical leaders in the HIV/AIDS response in Cameroon (Tih, 2018).

Considering the influence FBOs have on the prevention of HIV, CBCHB revised its policy in 2003, teaming up with FBOs, and adopted the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) (Kron, 2012). Likewise, in 2014, CDC/PEPFAR funded the Local Capacity Initiative (LCI) project submitted by the CBCHB, which was tailored to respond to the epidemic and scale up and improve the quality of HIV prevention of Mother-To-Child services in the Northwest and Southwest regions of Cameroon (CBCHB Free Projects, 2014). Similarly, Welty et al. (2005) proved that FBOs could be trusted, and it is best practice to include them in the day-to-day management of HIV/AIDS in Cameroon.

There is evidence of previous successful promotion of preventive practices for HIV/AIDs:

Baptist and PMTCT

Not many peer-reviewed articles exist on FBOs in Cameroon. There is, however, grey literature on the role of FBO in HIV care and prevention in Cameroon. For example, an article by Pius Tih Muffih, the DirectorDirector of the Cameroon Baptist Convention Health Services (CBCHS). CBCHS is a comprehensive health agency that is currently transforming HIV prevention in sub-Saharan Africa. The Government of Cameroon’s main HIV response collaborator and strategic pioneer in the reduction of PMTCT (Tih, 2018). Welt et al. (2005) have proven that FBOs could be trusted, and it is best practice to include them in the process of management for HIV/AIDS projects in the state. In this article, the authors describe a CBCSH project funded by the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF). The aim was to implement a program in PMTCT, which was successful (Welty et al., 2005). After 12 years, HIV seroprevalence decreased from an average of 10.3% in 2000 to 5.0% in 2011 among women tested in antenatal care and labor and delivery (Bonje, Khan, & Miller, 2012).

Museveni, Uganda, ABC

Other African countries have used FBOs in the successful management of HIV/AIDS. For instance, Uganda is one of the world’s first and most convincing national success stories in the domain of combating the spread of HIV (UNAIDS, 2004). Uganda’s early success in battling HIV included behavioral change campaigns aimed at decreasing the number of sexual partners among Ugandans. The president of Uganda used religious organizations to transmit the ABC slogan of HIV/AIDS behavioral change messages, which stands for Abstinence, Be faithful, and or use Condom if A&B fails, which t led to the success of HIV/AIDS prevention in Uganda (Green, 2001). In a way, the President of Uganda started a war against HIV/AIDS through communication via FBOs and social media. To the question of whether FBOs’ involvement was the game-changer, Green (2001) answered affirmatively by elaborating:

“There is some evidence from impact studies, such as those of a UNAIDS “Best Practices” project of the Islamic Medical Association of Uganda (IMAU) study (Kagimu, Marum, Wabwire-Mangen, et al. 1998), that AIDS prevention activities carried out through religious leaders have had a significant direct effect on, particularly targeted populations. It does appear that in situations in which religious organizations put emphasis (sometimes sole emphasis) on behavior change, in the form of abstinence and fidelity, the behaviors changed dramatically” (p. 10).

Unfortunately, today, the prevalence of HIV among adults aged 15 to 64 in Uganda is 6.2%, 7.6% among females, and 4.7% among males. It corresponds to approximately 1.2 million individuals aged from 15 to 64, who are living with HIV in Uganda (MoH, 2017). The author passionately believes that preaching prevention with the use of FBOs is not enough to make a difference. The results will be significant and sustainable if backed with the implementation of evidence-based practices on HIV/AIDS prevention because education alone is a weak, low-value improvement intervention. Education is often necessary but rarely sufficient without additional measures (Soong & Shojania, 2020). Here, the following limitations of education are highlighted:

• Education relies heavily on human memory and vigilance and does not guarantee that the new information will be correctly applied in the right circumstances and will lead to the desired behaviors.
• Education will not solve memory slips or lapses nor easily change habits or at-risk behaviors.
• Education does little to change system reliability.
• Education requires frequent repetition.
• Educating practitioners talking about desired behaviors might not be enough if there is external pressure to behave differently.

Beer et al. (2016) refer to healthcare’s reliance on education as the “great training robbery,” noting that systems spend large amounts of money and time on employee education without a good return on their investment. (p. 50). With all these solid reasons, it was wise to back up FBO preaching and education with some practical and evidence-based strategies.

Cameroonians prefer relying on FBOs in health-related matters when cures and treatment are scarce or non-existent. “Go back to God.”

AIDS has no cure, the only weapon one has is to rely on the prevention of the acquisition of new infections. Some notable factors from the HIV success stories are that behaviors have fundamentally changed when simple messages of abstinence, faithfulness, and use of condoms are communicated. Green et al. (2016), for example, are convinced that “these successful responses have often been community-based, low cost, low tech, and culturally grounded. Rather than relying on foreign technology, products, or expertise, they have been built on the knowledge, institutions, and cultures of affected communities” (p. 12). Religion or more specifically, faith-based organizations, influence the socio-cultural environment that decrease the risk of infection and allow to offer preventative interventions to the broader community. The world Council of Churches advocated for churches to be transformed in the face of the HIV/AIDS crisis so that they may become a force for the transformation and bring hope with healing and comfort to all affected by HIV/AIDS. The importance of religion-based organizations in the fight against HIV/AIDS has now become famous because churches have demonstrated time and again that their credibility, influence, and strength in the community can impact change in the behavior of people in that community (Ochillo et al., 2017).

Koenig (2009), a well-known researcher on religion, spirituality, and health, defines religion as the practices and rituals related to the sacred. These practices and rituals refer to Islam, Christianity, and indigenous beliefs, the primary forms of religion existing in Cameroon. (Schilder, 1988). Cameroon is a religiously tolerant country because the constitution allows freedom of conscience and religious worship. Christians form the bulk of the population, followed by Muslims and the indigenous believers (Schilder, 1988).

Based on the author’s childhood experience, religion is regarded with remarkably high esteem and is considered the most potent driving force in a typical Cameroonian family. When the resources are available, most Cameroonians will choose mission hospitals over government hospitals, mission schools over government schools. It is, however, regrettable that not many peer-reviewed articles exist on religion and HIV/AIDS in Cameroon, considering its importance for an average Cameroonian family. It is not strange because FBOs have historically played an essential role in delivering health and social services in developing countries, with extraordinarily little research on their role in HIV?AIDS prevention and care (Derose et al., 2010). The absence of recognition of the influence of religious organizations in the fight against AIDS is, however, not very strange because Gardner (2000) had called this doctrine a “virtual foreigner in the literature of AIDS since the year 2000” (p. 41).

In the same light, Jill Oliver (2000), in his article on the Religious and HIV/AIDS Policy, noted the “invisibility of religious organizations to the view of public health and policymakers” (p. 82). He further notes that it was only in the late 1990s religious organizations became partners in the fighting against HIV/AIDS in the African continent. Since then, religious organizations, as well as international NGO, such as UNICEF, WHO, and the Bill and Melinda Gates Foundations, developed an interest in sponsoring research on faith-based organizations in health matters (Olivier, 2011).

It is, therefore, imperative to emphasize the preventive aspect of the fight against HIV, which will probably help reduce the number of new infections. FBOs play a role in both prevention and treatment. One crucial role that they seem uniquely qualified to undertake is that of prevention, reducing the stigma associated with HIV in the faith community and the broader population. The Bishops of Cameroon had earlier echoed similar views when they called on the church to wage war against this pandemic, through sensitization, information, and educational activities, without hesitating to fall back on their cultural and spiritual values (NECC, 1999). Thus, Cameroon’s traditional religion and HIV/AIDS go hand in hand.

Capacity for care

FBOs are “hands-on” and follow-up closely with patients monitoring for their biophysical, spiritual, and social well-being while the government is mostly focused on the treatment aspect.

Faith-based organizations have proven their importance in the fight against AIDS, and they uniquely stand out because they are embedded in their local communities and have a global reach. Their large constituencies give them the advantage to play a vital role in advocacy and public awareness. Their presence on the ground permits them to go to places where government campaigns cannot reach. They are, therefore, well-positioned to act when emergencies arise (Ferris, 2005). FBOs are, in many cases,, the only genuine non-for-profit organizations in many rural parts of Cameroon. They always have a good comprehension of local social and cultural patterns, and larger ones may have reliable infrastructures. Many FBOs have experience working in healthcare and education domains, and there are many faith-based hospitals and schools in Cameroon. FBOs have the power to mobilize a substantial number of volunteers. They can be influential in policy debates concerning the legal, ethical, and moral issues surrounding AIDS and human rights (Lazzarini, 1998)

Limits to FBO Work in HIV/AIDs

Problems with the ABC method

FBOs emphasize the virtues of abstinence and faithfulness as the sole approach to prevention, which is why they face continuous opposition from other stakeholders who believe the promotion of condom use is more effective (Tiendrebeogo, 2004). However, FBOs strongly believe that promoting condoms will encourage sex outside of one’s marriage and promiscuity. They want to improve awareness of HIV-related knowledge, delay individual’s sexual debut, and decrease extra- and pre-marital sex (Tiendrebeogo 2004). On the other hand, prohibiting condom use will potentially reduce “knowledge, skills, and the willingness of members to use condoms during risky sexual behaviors, putting the lives of women at risk” (Murphy et al., 2006, p. 4).

Today, Uganda stands as a global reference point for its reported success in reducing the levels of HIV-1 infection from 30% in the mid-1990s to 10% within a decade (Green, 2003; UNAIDS, 2000). This success has become an international template for effective HIV/AIDS intervention, particularly in developing countries (Allen, 2006). Despite Uganda’s success, many controversies exist over this claim. One issue is that there is no convincing evidence that the country ever had a 30% prevalence rate (Allen, 2006). This is because, before 1995, demographic and health data was both limited and fragmented. Secondly, the first generation of HIV prevalence data can hardly be relied upon to supply a detailed representation of the number of infected persons.

The ABC model has become synonymous with a proper HIV/AIDS intervention (Slutkin et al., 2006). This attribution of success dedicated to the ABC model has influenced recommendations for international policies as well as funding and aid allocation decisions (Cohen, 2005). This evidence is highly contested, for example, Wawer et al. (1997) found emigration and mortality to be the most puzzling variables related to the observed decline in prevalence rates. Indeed, several studies commissioned by the United States government between 2002 and 2004 concluded that increased rates of abstinence and fidelity were the reason for the reported decline in HIV prevalence in Uganda in the 1990s (Green, 2003) Macintyre et al. 2001) found the personal experience of AIDS to be the most noticeable predictor of behavior change in working and married men aged 24-40.

The policy of openness, political will, and commitment are the key elements that led to increased awareness and understanding among the population. For example, awareness led to a reduction in HIV/AIDS prevalence and incidence (UAC, 2003). The government of Uganda itself has recognized the role played by NGOs, people living with HIV/AIDS (PLWHA), and community-based organizations (CBOs). Such recognition means that any success achieved in the struggle against HIV can hardly be attributed to a single factor or player. Therefore, learning the ABCs is not the only solution and more policy changes and practices should be implemented. It should be an ongoing process of governments and all other stakeholders working collaboratively to scale up quality, using evidence-based approaches that “fit” the national epidemic, followed by continuous monitoring and evaluating outcomes and strategizing (Collins, 2008, p. 9).

Other problems

FBOs’ attitudes and beliefs are judgmental towards people that are in same-sex relationships. Next, FBOs encounter organizational barriers because there is no structure that brings together all faith groups, and sometimes, disagreements and tensions between different FBOs and secular health organizations may limit the actions of FBOs. Collaboration with other organizations is needed for FBOs to operate to their maximum ability. They should complement the activities of others, reinforce the activities undertaken by others, ease the activities of these institutions, and support the activities undertaken by them (Derose et al., 2010). Moreover, leaders in the public health sector should creatively explore whether FBOs’ resources and skills can be successfully used to meet the urgent needs raised by the outbreak of HIV.

Discussion

The HIV/AIDS epidemic is still a global concern and there is the need to target Cameroon since it used to be the hardest hit region in 2004 with HIV prevalence rate estimated at 5.1%, the highest rate for the West and Central Africa sub-region. FBOs can influence socio-cultural factors that either increase or decrease the risk of HIV; and allow for preventative interventions to the whole community. Not many peer-reviewed articles exist on religion and HIV/AIDS in Cameroon considering the importance of these religious institutions for an average Cameroonian family hence grey literature comes in handy.

Potentially, FBOs are important players in HIV prevention and need more resources to support health promotion strategies. CBCHS is a robust health care organization now impacting HIV care and treatment in sub-Saharan Africa. It is also a key partner to the government of Cameroon in the HIV response and a technical leader in PMTCT.

Considering the role of FBOs in the management of HIV/AIDS prevention in Cameroon, and best practices in West and Central Africa that have had a significant impact in the fight against HIV is important because education alone is a weak, low-value improvement intervention: often necessary but rarely sufficient. Cameroon and Cote d’Ivoire are the least successful in terms of progress towards the UNAIDS 90-90-90 targets in PHIA states because management and accountability is a major setback. This is another reason why FBOs should play a core role in addressing the HIV/AIDS epidemic in Cameroon because they are more accountable and less corrupt.

Thus, the answer to the question, do FBOs in Cameroon follow best practices in the management of HIV/AItDS prevention? is: yes, they do. There is evidence supporting the necessity of including FBOs in the fight of HIV/AIDS. Model laws in HIV/AIDS may be in place to protect the essential rights of the women and the underprivileged. FBOs use BCC as an essential step in social marketing and VTC. STIs including HIV have always been the issues at the forefront of public health challenges. However, the most recent studies on STIs show that FSWs and MSM carry disproportionately high burdens of HIV. Still, they remain understudied and underserved owing to legal, ethical, and social challenges.

PMTCT is the brainchild of CBCHS, which has shown significant success in Cameroon and in Africa in general. Despite progress made in PMTCT, the pediatric HIV epidemic remains worrying in Cameroon. Nevertheless, many reports point to the beneficial effect of male partner involvement in programs for the MTCT of HIV in curbing pediatric HIV infections care and Treatment. Provided that FBOs can care for people, who live with HIV through a Medical Social Assistance Center, which is managed by the Ministry of Social Affairs, other development partners, and the Ministry of Public Health, FBOs’ use of PBP in fighting against HIV prevention in Cameroon can be a success.

Conclusion

The African Catholic Church through the voice of its Synod of Bishops advances the view that AIDS “is not to be looked at as either a medical pharmaceutical problem or solely as an issue of a change in human behavior. It is really an issue of integral development and justice, which requires a comprehensive approach and response” (as cited in Kelly, 2010, p. 251). The role of FBOs in HIV/AIDS prevention is extremely important but without internal development and justice, no amount of communication, education, ART treatments, or practices will do the job. The treatment must be holistic. Medical infrastructures must be developed, corruption must be abolished, and the rights of the underprivileged must be restored.

In this paper, I reviewed some of the commonly used practices for addressing HIV, such as the ABC method. The premise of raising awareness about this method is that by using the ABC, one can lead a life and engage in behaviors that will not subject them to exposure to HIV/AIDS. Although the Cameroonian government, the NGOs, and other states, including the United States understand the issue of the high prevalence of HIV/AIDS in Cameroon, there are several barriers to successfully fighting against the spread of this virus. The main issue is corruption and lack of accountability of the governmental organizations. Another issue is that FBOs typically condone the behavior of MSM and people who have relationships with the same sex.

In addition, the examples of Uganda as an African state that successfully reduced the number of HIV/AIDS infection cases from 30% of the population to 10% of the population is reviewed. Although some researchers question the validity of data, mainly the assessment methods used to estimate that 30% of Ugandans were infected with HIV in 1995, the country is perceived to be an example of a best practice and its experience is a template for other states in the region. Hence, the policies proposed in this paper can help curb the HIV/AIDS epidemic in Cameroon.

This review of the literature and the findings suggest that FBOs are suitable for implementing interventions that would target the HIV/AIDS issue in Cameroon, which is consistent with my experience. CLC type of paper is more suitable for this project since I have experience of living in Cameroon and I would like to help address issues, such as this epidemic with my future work. When living in Cameroon, I understood that FBOs play an important social role for the citizens. In terms of my Learning and Development Plan (LDP), this paper suggests that I should dedicate more attention to exploring the state-wide policies and health care interventions.

Reflection on Sustainable Development

At the 1992 United Nations (UN) Earth Summit in Rio de Janeiro, sustainable development was named one of the most urgent subjects for international policy. UN Agenda 21 was endorsed, proposing as part of its policy agenda a sustainable development plan based on the satisfaction of basic needs in developing countries. The Brundtland Commission defined the notion of sustainable development as the development that satisfies the needs of the present without having to compromise the needs of the future. There are some of the agreements that allow increasing the accountability of organizations in Cameroon as part of the development strategy below. Kate Raworth in her book titled Doughnut Economics put all humanity’s 21st-century challenge in a doughnut, and these are:

• To meet the needs of all within the means of the planet.
• To ensure that no one falls short on life’s essentials (from food and housing to healthcare and political voice), while ensuring that collectively we do not overshoot our pressure on Earth’s life-supporting systems, on which we fundamentally depend.
• Achieving sustainable development involves an economic, social, and quality environment enhanced by good governance to secure effective citizen participation in decision-making.

The sustainable development agenda for 2030 has a health issue at its center. One of the goals of this agenda is to ensure healthy lives of people and promote well-being for all citizens of all ages. HIV/AIDS is one of the elements that stand to hinder the achievement of these goals. It remains one of the challenges facing Africa and it is far more than a health issue. It is a general crisis impeding development by imposing a steady decline in the key indicators of human development and hence reversing the social and economic gains that African countries are striving to attain. Moreover, this is a question of poverty and underdevelopment, and it constitutes a challenge to human security and human development by diminishing the chances of alleviating poverty and hunger, achieving universal primary education, gender equality, reducing child and maternal mortality, and enabling environmental sustainability. For me to live the doughnut life, good life, “buen vivire”, I must ensure that my neighbors are safe. I must communicate, educate, advise, preach to the world the consequences and impact of HIV/AIDS.

2002 to the Code from Cameroon

Meeting during a follow-up workshop in Yaoundé on 25 and 26 October 2002, the signatory organizations to the Code adopted the following annex, which is an integral part of the said Code.

Annex 1:

• Ensuring transparency in elections within signatory organizations.

Transparency in elections is one of the guarantees of transparency within organizations. The signatory organizations undertake to strive for transparency at all stages of the electoral process, notably through the following measures:

• Publication, within reasonable timeframes, of the list of posts to fill, description of tasks and profile of posts.
• Definition and pre-dissemination of rules governing elections.
• Putting in place of a mechanism to facilitate the registration of candidates and voters.
• Selection of a neutral committee to organize elections.

Thesaid committee, comprised of people with established renown and integrity, could resort to expertise from people outside the organization.

• Public and solemn proclamation of election results, followed by a reminder on the duties and responsibilities of newly elected persons.

How to ensure protection for those who deplore acts of corruption within our organizations?

• Employees can be coaxed into becoming accomplices of corrupt practices, or be constrained from taking part in such practices by their bosses.
• Employees can be made to take note of acts of corruption and to denounce them or ask thought-provoking questions relating thereto.

In both cases, the employee is exposed to physical, mystical, and psychological threats and can lose his or her job.

One can distinguish two cases:

• Corruption at the helm of the organization, there is the will to effect change.
• The organization is entirely corrupt.

Signatory organizations have undertaken to adopt the following solutions, which are likely to ensure better protection for those who denounce corrupt practices:

• Adopt a code of procedures that expressly proscribes or prohibits acts of corruption and obliges every employee to denounce such acts.
• Make provision in all contracts, for a clause that will oblige all employees to denounce acts of corruption, failing which could make them the subjects to being laid off. The courts could possibly apply such protection.
• Recall that those who denounce corruption should base their claim on objectively verifiable facts. There are other measures which could be applied, but which have their limits.
• Encourage frequent meetings of team members, during which possible cases of corruption could be brought up. Such meetings, nevertheless, can be the framework within which “noise makers” (those with unjustified evidence of corruption) could be discovered.
• Encourage individual encounters between staff members and members of the Board of Directors. Hence, there is the risk that members of the Board of Directors could connive with Management if the latter is corrupt.

How to ensure the independence of the audit team?

Many cases in point can likely lead to an audit that is not independent or is of poor quality:

• Bad faith or incompetence of the auditor.
• The non-existence or non-respect of rules and procedures aimed at ensuring the objectivity of the auditor’s choice.
• The auditor’s dependence vis-à-vis the organization, which ensures a long- term contract for him as well as a direct and encouraging remuneration.
• The selection of the auditor by the Director of the organization alone.

The adoption of the following measures is likely going to strengthen the independence of the auditor:

1. Outline and publish procedures for selecting and dismissing auditors.
2. As best as possible, select an audit firm that has a reputation to preserve.
3. Establish a list of pre-selected candidates for auditing, to be submitted to funding bodies which will then proceed to the final selection.
4. Prohibit audit contracts on trial basis.
5. Lay down rules governing auditing within the organization.
6. Make a yearly assessment of the respect of procedures governing the selection and the functioning of the auditor, in a bid to carry out necessary rectifications.

Can the guiding code be respected without endangering the life of the organization, that is to say, can we function without being subject to corruption from without?

Organizations that are signatories to the code desire to curb corruption, but they operate in an environment wherein corruption for the most part continues to be the order of the day.

How can an organization exist – in carrying out its activities, in its relationships with other social actors – without participating in acts of corruption?

• There are three possible situations:
• Those who wield power can oblige us to give them money in order to carry out our activities.
• To secure a public contract, it is generally indispensable to “agree” with decision-makers.
• The tax scheme can be exaggeratedly unfavorable, to bring pressure to bear on organizations and oblige them to “agree” with civil servants who decide on such matters.

It is challenging to find a unique solution to this problem. Signatory organizations undertake to find solutions by gaining inspiration from the following proposals:

• It is not forbidden to give gifts to the authorities in question, in respect of the African tradition. Such gifts must however, be limited in their worth and nature.
• Organizations must improve the knowledge of their rights and execute their duties within stipulated time frames. A5) Youths Code of Conduct against Corruption, Cameroon 2002

We, the participants at the first FEMEC Youth Forum, holding in Buea, at the B.H.S. Campus, from 4th to 8th of August 2002, have this as a code of conduct to stamp-out Corruption for a transparent society in our country Cameroon (FEMEC is the Cameroon Federation of Protestant Churches and Missions).

The Youths should:

1. Know their rights and be courageous to stand by them.
2. Be modest in their doings, respectful, submissive, and patient.
3. Not emulate corrupt examples, practiced by our parents, friends and people in authority (1 Cor. 15:33).
4. Be honest and retire from giving and taking bribes.
5. Be united and fight for justice and equality for the good of the society.
6. Be imaginative, creative, and hard working to be self-reliant.
7. Not practice favoritism, nepotism, tribalism, and racism.

Refrain from forging documents from various purposes like:

• Birth Certificates
• Marriage Certificates
• School Certificates
• Traveling Certificates (VISAS)
• Employment Certificates
• Counter-feinting, etc.

1. Not be beneficiaries of any corrupt act.
2. Live their lives as the gospel of Christ requires (Phil. 1:27).

We the participants of this forum, hereby commit ourselves to this code, as we want the change to begin with us.

Done in Buea/Cameroon, on August 8, 2002.

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