Understanding the role of religious beliefs in adherence to antiretroviral therapy among Pentecostal Christians living with HIV in sub-Saharan Africa: a scoping review

Sub-Saharan Africa (SSA) continues to endure a disproportionate burden of HIV/AIDS, with an estimated 25.3 million people living with HIV (PLHIV) [1]. Many countries in the region are thus implementing the UNAIDS targets to end AIDS by 2030 [2]. The UNAIDS's 95–95-95 global targets recommend that by 2030 all countries should have 95% of PLHIV know their HIV status, 95% of those diagnosed with HIV enroll in ART, and 95% of those on ART achieve viral suppression [3].

Presently, more than 17.9 million PLHIV are known to be on ART in SSA. This outcome was partly achieved through the extensive adoption of the 2014 UNAIDS’s 90–90-90 targets and the Universal Test and Treat guidelines, which emphasize that every person who tests positive for HIV be initiated on ART irrespective of their CD4 count or WHO clinical staging [4]. However, in SSA, many PLHIV are still not on ART. In West and Central Africa particularly, out of 2.6 million PLHIV on ART, just about 39% of them have had suppressed viral loads because of non-adherence to ARTs [5].

Remarkable health benefits are being derived by PLHIV, public health, and healthcare providers from the use of ART in the control and management of HIV [6‐8]. Clinical markers such as viral loads and CD4 lymphocyte counts are usually used to assess the clinical efficacy of ART in PLHIV [9]. PLHIV who optimally adhere to taking at least 95% of ART as prescribed are known to experience undetectable viral loads and high CD4 counts [6, 8, 10]. Optimal adherence to ART is also known to prevent drug resistance and the need to switch patients to alternative treatment options that are more costly and difficult to deliver in healthcare settings in developing countries [11‐13]. Nevertheless, the benefits of good adherence to ART hinge on PLHIV’s ability to submit to a lifetime obligation of taking at least 95% of ART as prescribed [12, 14, 15]. Therefore, it is paramount that the factors that impact patients' adherence to ART are well understood and considered to achieve sustained treatment outcomes.

Practically, optimal adherence to ART is a challenging and ongoing process that depends on many factors, such as socio-economic, cultural, health systems, and therapy-related factors [16‐18]. Commonly reported patient-related factors impacting adherence to ART are substance abuse, emotional distress, treatment fatigue, and religious beliefs [19‐22]. Religion is essential in many people's lives, as over 88.7% of the world’s population professes at least one kind of religion [23]. In Africa, 47% of Africans are evangelized, and 49% are Christianized [24], and of the known Christian denominations, Pentecostal Christians are the fastest and the largest growing denomination [25]. A peculiar attribute of the Pentecostal Christians is their religious belief and practice of using the power of the “Holy Spirit” to heal people, especially those suffering from chronic diseases like HIV [26‐28]. Nonetheless, little is known about other religious beliefs pertinent to adherence to ART among Pentecostal Christians on HIV treatment.

Psycho-social factors have often been used to explain the adherence behaviors of people on chronic medications such as ART [29‐31]. Some people's religious beliefs have been reported to affect how they deal with HIV and other psycho-social factors influencing their treatment adherence, such as believing in the ART, disclosing, and accepting their HIV status, HIV stigma and discrimination, depression, and anxiety [32‐34]. Some studies assessing the impact of religion on ART adherence have found a positive correlation between religious beliefs and practices such as praying, attending regular prayer meetings, and church services [33, 35, 36]. Other studies have also demonstrated that religious beliefs have enabled Christians living with HIV to cope with common mental health problems such as depression, thus enhancing their ART adherence [34, 37, 38]. Religious beliefs have also been reported to help Christians living with HIV to access social support from church members and other institutions to enhance their adherence to HIV treatment [35, 37, 39].

The impact of religious beliefs on the prevention, management, and care of PLHIV in sub-Saharan Africa has also been acknowledged from the onset of the HIV pandemic [40]. Faith-linked organizations such as Islamic Relief, Tear Fund, Caritas Internationalist, World Conference of Religion for Peace, and the International Network of Religious Leaders living with HIV, are now partnering and assisting major stakeholders like the WHO and UNAIDS with resources to curb HIV transmission and strengthen adherence to ART and support to PLHIV [40].

On the contrary, the activities of some faith-based organizations have been negatively associated with information about HIV and adherence to ART among Christians living with HIV. Aspects of religious beliefs, like receiving healing through fasting and prayers, believing in the healing powers of pastors and prophets, or believing that HIV is spiritual and the demons causing it can be cast out through religious rituals, have been reported as barriers to adherence to ART [17, 28, 33]. The belief of some prominent spiritual leaders in using unconventional healing methods like drinking petrol, eating grass and snakes, and spraying insecticides on their church members to heal them from various health problems has been reported [41]. Healthcare workers have also reported the belief in the potency of spiritual healing over orthodox ART in different settings [42‐44]. The use of unusual religious beliefs and rituals for the treatment of HIV have equally been well documented as barriers to adherence to ART [27, 28, 45], thus thwarting the medical community’s efforts to enroll and maintain Christians living with HIV on HIV treatment [35, 36, 46].

To mitigate religion-related barriers to adherence to ART among Christians living with HIV, knowledge of religious beliefs and practices hindering optimal adherence has often been employed in designing ART adherence interventions, especially in the counseling components of such interventions. It has also been recommended that healthcare professionals discuss spirituality or religious issues with individuals and establish their role in managing patients [34].

The literature describing religious-embedded adherence interventions to improve ART adherence among Christians living with HIV is generally limited [36, 47]. Previously reported data on the negative impact of religious beliefs on ART adherence outcomes, especially in SSA, have been predominantly anecdotal accounts obtained from studies with limited respondents and not based on established empirical methods [33]. There have also been calls from some stakeholders to embed religion into HIV-care to improve the physical and mental outcomes of PLHIV. Nonetheless, the varied nature of the support from various stakeholders conducting spiritual assessments and providing spiritual care in healthcare settings have been reported as setbacks in such interventions [47]. Alternatively, more collaboration with alternative medicine providers such as Pentecostal Christian religious leaders, spiritual prophets, and pastors has also been recommended as a way forward to fortifying adherence to ART among Christians living with HIV [26, 28, 48].

Worldwide, many people belong to organized religions, and depending on their respective religious affiliations, their religious beliefs and practices can influence their healthcare beliefs and practices [49]. While some people on ART have used their religious beliefs and practices to access psychosocial support from other church members or organizations and achieved good clinical outcomes, others have applied theirs differently, thus compromising their commitments to taking ART as prescribed, leading to poor clinical outcomes [33]. Relevant information on the religious beliefs and practices of Christians living with HIV can be integrated into their HIV treatment plans. Such information can also be helpful to healthcare professionals in developing better ART adherence strategies and consequently obtaining optimum health outcomes for PLHIV. Nonetheless, there is still a paucity of evidence, particularly in SSA, concerning religious beliefs relevant to ART adherence among Christians living with HIV [37]. Consequently, we employed a scoping review methodology to explore and hypothesize the relationships between religious beliefs and adherence to ART among Pentecostal Christians living with HIV in SSA.

The authors first developed a scoping review protocol [50] as part of a larger study to understand the adherence behaviors of Pentecostal Christians living with HIV to ART to enhance guidelines development [51]. However, we did not register the protocol before writing this scoping review. According to Colquhoun et al. [52], a scoping review is a form of knowledge synthesis that addresses an exploratory research question aimed at mapping key concepts, types of evidence, and gaps in research related to a defined area or field by systematically searching, selecting, and synthesizing existing knowledge. This scoping review was conducted following the methodological steps suggested by Arksey and O’Malley [53]: (i) identification of the research question; (ii) identification of relevant studies for the scoping review; (iii) selection of the literature for the scoping review; (iv) charting the data; and (v) collating, summarizing and reporting the results. The PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation from Tricco et al. [54] was used to ensure that the scoping review was reported accordingly (see the Supplementary File 1). We used a narrative synthesis to summarize the data extracted to report on the nature of existing evidence and the impact of religious beliefs on ART adherence among Pentecostal Christians living with HIV in SSA.

We obtained 1,239 hits from 8 databases searched (see Table 2). Of this number, 438 were duplicates and were removed, while 801 papers were retained. After screening for possible relevant titles and abstracts of the retained 801 papers, 780 did not qualify for full-text screening and were removed because either their titles or abstracts were irrelevant to the study. However, 21 papers qualified for full-text screening and were retained. A further search was conducted on Google Scholar, which yielded nine other papers since one paper was excluded because we could not retrieve its full text. Later, a reference list search was conducted on the papers that qualified for full-text screening, and six additional studies were found and added to the 21 initial papers eligible for the full-text screening. Thus, 36 papers (21 + 9 + 6 = 36) passed through full-text screening and 7 of them met the inclusion criteria and were included in the review. Figure 1 provides a flow chart of the study selection process.

This scoping review was designed to provide insight into the relevance of religious beliefs among Pentecostal Christians living with HIV in SSA concerning ART adherence. Evidence shows a multifaceted impact of religious beliefs on ART adherence among Pentecostal Christians living with HIV. In the first facet, religious beliefs such as religious rituals, prayers, testimonies, prophecies, biblical scriptures, and the influence of religious leaders promoting spiritual healing and deliverance over conventional ART hinders adherence to ART among Pentecostal Christians living with HIV. This finding draws attention to the potential negative role that religious beliefs can play in adherence to ART among some Pentecostal Christians living with HIV. Previous studies [19, 22, 42] reported the detrimental potential of religion to ART adherence among some highly religious people based on their unweaving belief in healing through prayers, holy water, and other faith-based healing rituals. In this review, Tumwine et al. [33] also identified teachings and prophecies from religious leaders and supporting Biblical scriptures to have led Pentecostal Christians living with HIV to feel that God and their faith in Him, and not ART, would heal them.

One of the current global targets of the UNAIDS in ending HIV by 2030 requires that PLHIV on ART achieve a 95% suppressed viral load [3]. Given this objective, knowledge concerning what motivates or facilitates optimum adherence to ART or developing strategies to strengthen adherence to ART is relevant. Four aspects of religious beliefs identified to facilitate good adherence to ART that could be harnessed to improve ART adherence among people with Pentecostal beliefs living with HIV are: (1) God needs everyone to fulfill his or her purpose on earth, (2) God heals through doctors, (3) not taking ART is putting God to the test, and (4) God gave scientist the knowledge to manufacture ART. This finding shows that religious beliefs are not always unhelpful or act as deterrents in sustaining long-term adherence to ART among Pentecostal Christians living with HIV. To this end, we suggest that spirituality should be considered when designing adherence interventions, especially in the counseling components of such interventions. It has also been recommended that clinicians discuss spirituality or religion with individual patients and determine its role in managing HIV treatment in patients case-by-case [34].

Our finding shows that religious beliefs also influence the psychosocial factors motivating or facilitating good adherence to ART among Pentecostal Christians living with HIV. We identified that positive coping with depression, anxiety, and stress led to improved adherence to ART among some Pentecostal Christians living with HIV. However, positive coping with problems of medication side effects of ART was also reported in the study by Ayuk et al. [37], while positive coping with stigma and discrimination, which are the most frequently reported reasons why patients default on ART, were also reported in Tumwine et al. [33]. In the same study, the conventional belief in God as a source of comfort and support was reported to enable Pentecostal Christians living with HIV to cope with mental health symptoms associated with inadequate adherence as opposed to fundamentalist beliefs in the healing power of God which causes some Pentecostal Christians living with HIV to abandon ART. Pentecostalism also enabled some Pentecostal Christians living with HIV to access social support from church members and other institutions, thus enhancing adherence to ART [35, 37, 39]. Koenig [61] found a positive association between positive religious coping and adherence to ART and suggested that positive coping may be linked to improved attendance to scheduled medical appointments and better compliance with ART. Conversely, negative coping, like feeling abandoned by God, reported among adolescents to be associated with poor adherence to ART by Lyon et al. [62] was not reported in any study in the review. This phenomenon could be explained by the fact that most Pentecostal Christians have an unweaving belief that God can never forsake or abandon them, no matter their situation.

Knitting the relationship between Pentecostalism, ART-related psychosocial issues, and ART adherence among Pentecostal Christians living with HIV through abduction provides a comprehensive picture (Fig. 3). This hypothesized relationship (model) shows Pentecostalism's dynamic and multidirectional influence on ART adherence for some Pentecostal Christians living with HIV. The model demonstrates the relationship between Pentecostalism and ART adherence being mediated by Pentecostalism, addressing psychosocial issues related to ART adherence and improving patients’ resilience to social adversity such as stigma and discrimination. In turn, the achieved resilience and self-efficacy reinforce patients' beliefs (based on Pentecostalism and its practices), fortifying their resilience and self-efficacy. Such a model can be helpful in further exploring and refining these relationships and designing robust interventions to address ART adherence among this population. The need for such a model is critical because of the conspicuous dearth of religious-embedded ART adherence studies in SSA, particularly among Pentecostal Christians.

Religious beliefs have a multifaceted impact on adherence to ART among some Pentecostal Christians living with HIV in SSA. More religious beliefs negatively influence adherence to ART than those that motivate or facilitate good adherence in this scoping review. While some Pentecostal Christians living with HIV on ART use their religious beliefs and practices to access psychosocial support from other church members or organizations and achieve good clinical outcomes, others apply their religious beliefs and practices differently and compromise their commitments to taking ART as prescribed, thus experiencing poor viral suppression and clinical outcomes.

However, there is still a premature understanding of the nature of religious beliefs and how they impact ART adherence among people with Pentecostal beliefs living with HIV in SSA. We elicited a model to inform further thinking on the role(s) of a system of beliefs, moral values, or codes of conduct and practices and how and why they influence the decisions of some Pentecostal Christians living with HIV regarding testing, acceptance of HIV test results, initiating ART and adhering to the treatment. A refined version of such a model can inform interventions and ways of improving ART adherence among Pentecostal Christians living with HIV and other PLHIV who share their religious beliefs.